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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 02/09/2023
Date Signed: 02/09/2023 05:04:58 PM

Substantiated


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
10/31/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221031103835
FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
557005532
ADMINISTRATOR:CATHY HELTONFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 102DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Mark CrowderTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not ensure medication orders were followed by staff
INVESTIGATION FINDINGS:
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Allegation: Staff did not ensure medication orders were followed by staff.

It was alleged that staff did not ensure medication orders were followed by staff. Throughout the investigation, LPA reviewed facility files which included but are not limited to Medication Administrator Records, Physicians orders, Emergency contact lists, and physicians’ reports. In addition, LPA conducted several staff interviews.

It was stated by staff members who were interviewed that the medication technician on duty on 09/02/2022 provided Lorazepam to a resident, twice. A review of the resident’s medication record was conducted and it was learned that the facility holds a paper Medication Administrator Record (MAR) and two Electronic Medication Administration Record (E-Mar) Systems. One E-Mar reflects current medication to be administered and the second E-Mar allows medication technicians to check off medication as they are provided to the resident. A review of the Electronic MAR did not reflect that the resident was prescribed Lorazepam as a PRN to be provided once nightly for agitation.
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
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 5
Control Number 27-AS-20221031103835
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: 02/09/2023
NARRATIVE
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 Based on records review, the Paper MAR did reflect that the resident was prescribed Lorazepam as a PRN on 06/26/2022. On 09/2/2022, the paper MAR reflects that the resident was given Lorazepam, twice between 5:30pm and 09/03/2022 at 1:00am by the same Medication Technician. On 09/03/2022 at 7:30am, the Medication Technician found the resident unresponsive in the dining room and called 911 to transport the resident to the hospital.

Upon further investigation by the facility, it was learned that the resident received a second dose of Lorazepam 8 hours after the first dose. As a result, the facility did not ensure that medication orders were followed by staff.

Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with facility representative and a copy of this report was provided along with appeal rights.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20221031103835
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: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited
CCR
87465(c)(2)
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87465(c)(2): Incidental Medical and Dental Care:(c) ...provided all of the following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidence by:
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The Administrator will conduct an in-service training regarding the section 87465(c)(2). A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the
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Based on documentation and interviews, the Facility did not comply with the section cited in 87465(c)(2). Based on documentation and interviews conducted, it was found that staff provided a resident medication twice within an 8 hour period, which was against the prescription that was provided by the physician. This poses an immediate health and safety risk to clients in care.
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 LPA’s email at Arielle.pascua@dss.ca.gov by the due day of 02/10/2023 Close of Business. Information submitted must include attendees, trainers, and information discussed. LPA’s email at Arielle.pascua@dss.ca.gov by the due day of 02/10/2023 Close of Business. Information submitted must include attendees, trainers, and information discussed.
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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: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/31/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221031103835

FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
557005532
ADMINISTRATOR:CATHY HELTONFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 102DATE:
02/09/2023
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Mark CrowderTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not ensure resident was safe from being sexually abused
Staff did not ensure physician orders were not altered
INVESTIGATION FINDINGS:
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Allegation: Staff did not ensure resident was safe from being sexually abused

It was alleged that staff did not ensure resident was safe from being sexually abused. Throughout the investigation, the department reviewed facility files and conducted interviews. Based on staff interviews conducted, all staff denied every witnessing S1 ever being inappropriate with a R1. Staff also reported that they do not believe S1 would ever be the type of person to inappropriately touch a resident and never noticed any red flags. An interview with S1 was conducted, and S1 denied the allegation and reported that they only want the best for the residents and their care.

Continued
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20221031103835
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: 02/09/2023
NARRATIVE
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Several resident interviews were also conducted. All residents interviewed either did not know who S1 was or had no complaints against S1. Resident who did recall S1 stated that they provided good care and was attentive to their needs. It was also learned during interviews that the witness could not confirm that S1 was being inappropriate with the resident. It is unclear at this time if staff did not ensure that the resident was safe from being sexually abused.

Allegation: Staff did not ensure physician orders were not altered

It was alleged that staff did not ensure physician orders were not altered. Throughout the investigation, facility files were reviewed and interviews were conducted. Based on staff interviews it was learned that S2 informed other staff members that they provided R2 with CBD infused cotton candy due to a new prescription provided by the physician. Upon medication review, the facility found that R2 did not have an active prescription order for CBD. Staff informed the Facility Designated Administrator and contacted the physician for a prescription. It was also learned that S2 was hired by family independently and was asked to accompany R2 to a recent doctors appointment. During this appointment S2 asked the doctor for a prescription for CBD for the resident. It was confirmed by the facility that the physician did not provide R2 a prescription for CBD. Shortly after, S2 bought CBD and provided it to the resident. At the time the facility did not have an active prescription for CBD from the physician. It is unclear at this time if staff did not ensure physician orders were not altered.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.


There were no deficiencies observed or cited at this time. An exit interview was conducted
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5