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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005532
Report Date: 06/22/2023
Date Signed: 06/29/2023 03:56:39 PM


Document Has Been Signed on 06/29/2023 03:56 PM - 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 LIVINGFACILITY NUMBER:
557005532
ADMINISTRATOR:MARK CROWDERFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 108DATE:
06/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:11 PM
MET WITH:Armando RodriguezTIME COMPLETED:
05:00 PM
NARRATIVE
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On 06/22/2023 Licensing Program Analyst (LPA) Kimberly Viarella and Licensing Program Manager (LPM) Liza King made an unannounced visit to this facility to open a complaint. The purpose of the visit was explained. Licensing representatives met with the Designated Facility Administrator (DFA) Armando Rodriguez and received a facility tour by the Community Relations Director (CRD) of the laundry rooms (2) and the Memory Care Neighborhood.

During the facility tour, the LPM observed two residents’ bedrooms in the Memory Care neighborhood with toxins that pose an immediate risk to the residents in care. Bedroom one contained desitin cream, 3 containers of toothpaste, vicks vapor rub, phytoplex, aloevesta cleansing foam, disposable ice bag, and 3 containers of babyfood in the dresser drawer, one of which had been opened. Bedroom 2 contained a bottle of Lubidern lotion. These items were removed during the visit and facility staff were instructed by the CRD and check of the bedrooms, closets and drawers for any other toxins.

Based on observation citations are issued for the above information and are attached to the report. Exit conference was conducted and the report and appeal rights were provided to the DFA.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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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Document Has Been Signed on 06/29/2023 03:56 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2023
Section Cited
CCR
87705(f)2

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Dementia Care for Residents 87705(f)2
(f) toxic substances...(2)... Over the counter medications...and toxic substances...
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Administrator will train the staff on doing room checks an will perform pop inspections.
Administrator will send copies of the training components to kimberly.viarella@dss.ca.gov by the due date.
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This requirement was not met as evidenced by: Based on observations and interview, 9 toxic items were found in 2 residents' bedrooms in Memory Care. This posed an immediate health and safety risk to residents in care.
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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: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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