557005532-6-1-2023-27-AS-LKIG-CSDPMK-20230601112629

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 557005532
Report Date: 05/31/2023
Date Signed: 06/01/2023 11:27:57 AM

Document Has Been Signed on 06/01/2023 11:27 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:	DATE:	05/31/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:			TIME COMPLETED:	10:06 AM

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	An Informal Conference was conducted today, 05/31/2023, via Microsoft Teams. The purpose of the Informal Conference was to discuss the facilities compliance with Title 22 Regulations. There have been 13 Type A deficiencies in the recent past. The informal conference process was explained by the Licensing Program Manager (LPM) Liza King. Census was reported to be 90 in Assisted Living and 18, (the maximum allowed) in Memory Care. The following were present at today’s conference: Licensing Program Manager (LPM) Liza King, Licensing Program Analysts (LPAs) Kimberly Viarella and Arielle Pascua, and Facility Executive Director, Mark Crowder. Milestone representatives included: Regional Director of Operations, Cathy Helton, Vice President of Regulations and Compliance, Ginger Tarabocia, Chief Strategy Officer, Natalie Ross, and Nurse Support Manager, from the Allen Flores Consulting Group, Melissa Quaranto. Additional guest, Long Term Care Ombudsman, Jill Engle was also present. The following issues were discussed during the informal conference: · Appraisals: AWOLs, Personal Care Needs · Needs and Services · Sufficient Staffing, including confirmation of current staffing agency contracts Assisted Living: 3 Caregivers AM / 2 PM, 1 NOC. Memory Care Staffing: 2 AM /2 PM, 1 NOC. This does not include Medication Technicians who also provide care when needed. · Training which includes updates to the Onboarding process. · Medications, Dashboards are monitored daily and reports are run monthly to ensure that medications are being given as prescribed. Cont on 809C

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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: 05/31/2023

NARRATIVE

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Licensees stated they will do the following to achieve continued and substantial compliance:
- An Administrator will continue to be present 40 hours / week
- Submit new LIC 500 personnel report with updated staff schedules (cross-referenced with Guardian) by
5:00 PM 06/05/2023.
- Submit an LIC308 by 5:00 PM 06/05/2023.
- Print task lists for caregivers weekly instead of monthly to ensure updated information is provided to staff,
beginning in June 2023
- Executive Director to select 12 different topics for outside resources (Hospice, Ombudsman, etc.) and
internal staff to conduct training's on once a month beginning in July 2023.

Licensing will:
Increase monitoring to verify:
- Appraisals and Reappraisals are completed.
- Medications are Administered as prescribed and documented as necessary.
· Internal Audits of Medications is being completed by the facility.
Staffing is sufficient to meet the needs of the residents.
Task sheets are being printed weekly and provided to staff

The first quarterly visit will begin on or about September 2023.

Licensees were offered and DECLINED an opportunity to participate in Department's Technical support Program.

No deficiencies were cited from the California Code of Regulations, Title 22, Division 6 as a result of today's meeting. An exit interview was conducted with Mark Crowder, the Executive Director, via telephone and a facility report was provided via email read receipt.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

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