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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 08/24/2022
Date Signed: 08/25/2022 08:36:56 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20220315162308
FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
557005532
ADMINISTRATOR:ILONA ROZA CORPUSFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 99DATE:
08/24/2022
UNANNOUNCEDTIME BEGAN:
04:14 PM
MET WITH:Facility Staff, Mark CrowderTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Resident sustained a death while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility on 08/24//2022 unannounced to deliver findings on the above allegations. LPA Hurt met with facility staff Mark Crowder and explained the purpose of today's visit.

Regarding the allegations Resident sustained a death while in care. Based on records reviewed Resident 1 was not in the facilities care at the time of their death. LPA reviewed hospital records documenting Resident 1 was in the care of the local hospital when they died, and therefore this allegation is UNFOUNDED.

No deficincies cited today Per Title 22 Regulations.Exit interview conducted with Facility staff Mark Crowder.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/15/2022 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20220315162308

FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
557005532
ADMINISTRATOR:ILONA ROZA CORPUSFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 99DATE:
08/24/2022
UNANNOUNCEDTIME BEGAN:
04:14 PM
MET WITH:Facility Staff, Mark CrowderTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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9
Staff did not address a resident's change in medical condition
Staff did not seek timely medical attention for a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility on 08/24//2022 unannounced to deliver findings on the above allegations. LPA Hurt met with Facility staff Mark Crowder and explained the purpose of today's visit.

Regarding the allegations staff did not address a resident's change in medical condition. Based on interviews, and records reviewed the staff did not address Resident 1’s (R1) change in condition. Witnesses stated they contacted the facility on 02/08/2022 to speak to R1 and informed the medication technician in R 1’s room of R1’s inability to urinate and that R1 needed help RIGHT NOW. The witness was told by the medication technician present in R1’s room at the time it would be addressed right away. The witness stated they called the facility again on 02/10/2022 to speak with R1. R1 reported they were not feeling well, and no one had addressed the urination issue. R1 was transported to the hospital on 02/10/2022 and was admitted for care. R1 died at the hospital on 02/19/2022. The facility was aware of Resident 1’s change in medical condition for several days before it was addressed therefore this allegation is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20220315162308
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SKYLINE PLACE SENIOR LIVING
FACILITY NUMBER: 557005532
VISIT DATE: 08/24/2022
NARRATIVE
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Continued from 9099...

Regarding the allegation staff did not seek timely medical attention for a resident. Based on records reviewed the facility did not provide timely medical care for R1. LPA reviewed hospital records documenting facility staff informed hospital staff on 02/10/2022 of R1 having urinary frequency and dysuria for the previous 5 days. The hospital records dated 02/10/2022 also document facility staff reported Resident was having shortness of breath and coughing for two to three days prior. Resident 1 was admitted into the hospital on 02/10/2022 with pneumonia and sepsis. R1 then died in the hospital on 02/19/2022. LPA reviewed facility care notes documenting Resident 1 “felt fine” on 02/07/2022 with no further updates until 02/10/2022 when it is documented Resident 1 was admitted into the hospital. Based on hospital records, the facility staff was aware of Resident 1 needing medical attention for several days before seeking medical care. Based on this information, the allegation is SUBSTANTIATED.

An immediate $500.00 civil penalty was assessed on this day based on the allegation: "Facility failed to provide medical attention to resident in care." R1 was admitted to the hospital with pneumonia and sepsis which then resulted in their death. The Licensee was informed today that a Civil Penalty may be assessed at a later date based on Health & Safety Code Section 1569.49. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties.


The following deficiencies were cited per Title 22 Regulations. Exit interview conducted with Mark Crowder and a copy of this report was left at the facility along with appeals rights provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220315162308
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SKYLINE PLACE SENIOR LIVING
FACILITY NUMBER: 557005532
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2022
Section Cited
CCR
87466
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87466 Observation of the Resident .
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. The following requirement has not been met as evidenced by:
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Administrator will conduct training with all facility staff on Observation of residents and submit proof to LPA by 08/25/2022 POC date.
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Based on records reviewed R1's change of condition was not addressed by facility staff in a timely which poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
08/25/2022
Section Cited
CCR
87465(a)
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87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The following requirement has not been met as evidenced by:
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Administrator will provide training on incidental medical and dental care to all facility staff and send proof to LPA by 08/25/2022 POC date.
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Based on interviews and records reviewed R1 was not provided medical care until days after staff was alerted of her condition which poses an immediate health, safety, or personal rights risk to residents care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4