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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005532
Report Date: 04/06/2023
Date Signed: 04/07/2023 08:12:35 AM


Document Has Been Signed on 04/07/2023 08:12 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 LIVINGFACILITY NUMBER:
557005532
ADMINISTRATOR:MARK CROWDERFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 103DATE:
04/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mark Crowder TIME COMPLETED:
01:30 PM
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On 04/06/2023 at 12:30pm, Licensing Program Analysts (LPAs) Arielle Pascua, Christina Valerio, Kimberly Viarella arrived at this facility unannounced to conduct a case management visit. LPAs met with Facility Designated Administrator, Mark Crowder and explained the purpose of the visit. The purpose of this visit is to follow up on an incident that was received by the department on 02/07/2023.

Current census was 103. A brief interview with FDA Crowder was conducted. A tour of the facility was conducted.
The incident report received on 02/07/2023 states that R1 drove away from the community in their vehicle. It was stated by the facility that the resident cannot leave community without an escort. This the course of the visit LPA obtained the resident's Physician Report, Needs and Appraisals plan, Emergency contact sheet, and care notes.

The LPA will return at later date to complete the case management visit.

No deficiencies cited on this day.
An exit interview was conducted. A copy of this report along with a confidential names list was provided to the facility via email. An electronic response from FDA Crowder confirms receipt of this report.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023
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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