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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005532
Report Date: 10/01/2021
Date Signed: 10/01/2021 07:55:29 PM

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:STEPHANIE OLLEYFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 111DATE:
10/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rebecca Wright, Business Office ManagerTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Sarah Hurt conducted an unannounced visit today for the facilities annual inspection. LPA met with Business Office Manager Rebecca Wright. There are currently 111 residents who reside at this home and there is 1 resident on hospice at this time. LPA Inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 109 F degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

The following deficiencies are being cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with staff and copy of report left at facility
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.2(c)



Basic Services
(c) "care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities for daily living without which the residents physical health, mental health, safety, or welfare would be endangered. Assistance includes with taking medications, money management or personal care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPA reviewed electronic MARS and noticed residents were missing medications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2021
Plan of Correction
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facility will make up a solid schedule and send to LPA assigning specific med techs to specific residents to remain on a constant schedule for re ordering meds.
Type A
Section Cited
CCR
87211(a)(2)
CCR 87211(a)(2)
Reporting Requirements (a) each licensee shall furnish to teh licensing agency such reports as the Department may require, including but not limtited to, the following: (2) occurences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of the residents, personnel or visitiors, shall be reported within 24 hours either by telephone or fascimile to the licensing agency or local health department.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. SIR's are not being sent over within 24 hours. This poses an immeidate health and safety risk to residents in care.
POC Due Date: 10/04/2021
Plan of Correction
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Administrator will provide declaration of understanding of the regulation. Also training for all staff who submits incident reports.
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: 10/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2021
LIC809 (FAS) - (06/04)
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