557005532-6-9-2023-27-AS-KVIA-CSMNTG-20230609104444

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 557005532
Report Date: 05/30/2023
Date Signed: 06/09/2023 10:44:53 AM

Document Has Been Signed on 06/09/2023 10:44 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
SACRAMENTO AC/SC, 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:	05/30/2023
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Mark Crowder		TIME COMPLETED:	10:00 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 Present at today's Informal Conference were: Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Kimberly Viarella and Arielle Pascua and Executive Director, Mark Crowder. Milestone representatives included Cathy Helton, Ginger Tarabocia, and Natalie Ross. Additional guests, Melissa Quaranto, and Long Term Care Ombudsman, Jill Engle were also present. The informal conference process was explained during this meeting. 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 staffing and Memory Care staffing · Training · Medications Licensees stated they will do the following to achieve continued and substantial compliance: · An Administrator will be present 40 hours / wk. · Submit new LIC 500 personnel report with updated staff schedules (cross referenced with Guardian) by 5:00 PM 06/02/2023 · Submit a LIC308 by 5:00 PM 06/02/2023 · Submit procedures for ensuring medications are given as prescribed by XXXXXX. · Create a tracking system to ensure the necessary appraisals are completed timely based on the needs of the residents. Continued on LIC 809C

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SKYLINE PLACE SENIOR LIVING	FACILITY NUMBER: 557005532
	VISIT DATE: 05/30/2023

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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 are sufficient to meet the needs of the residents
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 XXXXXXXXXXX via telephone and a facility report was provided via email read receipt.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly Viarella	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023

LIC809 (FAS) - (06/04)

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