557005532-2-3-2023-27-AS-APAA-CNPMK7-20230203084016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 557005532
Report Date: 02/01/2023
Date Signed: 02/03/2023 08:40:29 AM

Document Has Been Signed on 02/03/2023 08:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	MARK CROWDER		FACILITY TYPE:	740
ADDRESS:	12877 SYLVA LN		TELEPHONE:	(209) 588-0373
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY:	135	CENSUS: 95	DATE:	02/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Mark Crowder		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 2/1/2023 at 11:00am, Licensing Program Analysts (LPAs) Arielle Pascua and Christina Valerio arrived at this facility unannounced to conduct a 1-year annual visit. LPAs were greeted by Facility Designated Administrator, Mark Crowder and explained the purpose of the visit. The current administrator holds a current administrator certificate #6015244740 and expires on 6/10/2024. A brief interview was conducted with FDA Crowder. This facility is licensed for 135 residents of which 35 may be bedriidden and has a current hospice waiver for 6. Current Census was 95. LPAs initiated a tour with FDA Crowder. A tour of the facility was conducted. Living areas, dining areas, and all other areas intended for resident were toured and observed to contain adequate furniture and furnishings to meet the needs of the residents at this time. Kitchen area was toured. Food supply was reviewed for 7-day nonperishable and 2-day perishable food quantities. 7-Day nonperishable food supply was located in a separate closet away from the kitchen. LPAs observed there to around 40 gallon cans of various fruits and vegetables, 1 box of nature valley bars, a bag of tortilla chips, 3 boxes of chocolate candy, several potatoes, and several boxes of souffle cups and other containers. A tour of the resident rooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents. A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/01/2023

NARRATIVE

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Medication cabinet was reviewed. It was learned that narcotics and all other medications were housed in medication carts that were used to store and dispense medications to the residents at this time. This facility employed an electronic Medication Administration Record system at this time. A brief interview was conducted with facility staff responsible for handling, dispensing, and documentation of the medications at this time.

Fire extinguishers, located and placed throughout the facility, were observed to have been annually inspected on 03/01/2022 by Cisco Fire Sprinklers.
A tour of the exterior grounds was conducted. A review of the perimeter fence and side gates was conducted and observed to have no hazards present.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

Liability Insurance

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

Appeal rights were printed and a copy was given to the facility designated Administrator.

Exit Interview.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/03/2023 08:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(26)

87555(b)(26) General Food Service Requirements: The following food service requirements shall apply... Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidence by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply by not ensuring a sufficient amount of non-perishable food supplies available for current amount of residents in care at the facility. LPAs observed there to around 40 gallon cans of various fruits and vegetables, 1 box of nature valley bars, a bag of tortilla chips, 3 boxes of chocolate candy, several potatoes, and several boxes of souffle cups and other containers. This poses an immediate health, safety or personal rights risks to persons in care.
	POC Due Date: 02/02/2023
	Plan of Correction
1 2 3 4	The Adminstrator agrees to purchase the required supply of non-perishable food supply for the facility and send in a receipt for proof of purchase by the POC date 02/02/2023 to the LPAs email at arielle.pascua@dss.ca.gov

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC809 (FAS) - (06/04)

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