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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 06/22/2023
Date Signed: 06/29/2023 04:26:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/29/2023 and conducted by Evaluator Kimberly Viarella
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230329101714
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
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Armando RodriguezTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff are not meeting residents' showering needs.
Facility staff are not meeting residents' incontinence needs.
Facility staff not conducting planned activities for the residents.
INVESTIGATION FINDINGS:
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On 06/22/2023 Licensing Program Analyst, (LPA) Kimberly Viarella visited this facility to deliver complaint findings. LPA was met by Armando Rodriguez, Designated Facility Administrator. The census at the time was 108 residents.

FACILITY STAFF WERE NOT MEETING RESIDENTS' SHOWERING NEEDS. Based on observation, a review of records, and information gathered through interviews, it was determined that residents were not receiving their showers when scheduled. Residents were observed to be unshowered and ungroomed wearing the same clothes for multiple days. This LPA learned that the implementation of the Shower, Laundry, Trash, Dog Walker position, was instituted to ensure that all residents would receive their showers according to the schedule, or as needed. During this investigation, it was learned that these individuals only worked in the Assisted Living section of the facility. Residents in Assisted Living and in Memory Care did not get their showers as scheduled. Some Residents require a 2-person assist and if a second person was not available, the shower or change was delayed/postponed, thus not following the schedule.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20230329101714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/22/2023
NARRATIVE
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FACILITY STAFF WERE NOT MEETING RESIDENTS' INCONTINENCE NEEDS. Based on observation, a review of records, and information gathered through interviews, It was determined that residents were left in wet depends for extended periods of time. Gel beads from soaked depends were found stuck to the residents’ bottoms showing that they were not being cleaned thoroughly between changings. Their red irritated skin also provided evidence that residents were left in these wet depends for long stretches of time.

FACILITY STAFF NOT CONDUCTING PLANNED ACTIVITIES FOR THE RESIDENTS. Based on interviews, observation and records review, it was learned that there weren't many activities in Memory Care. This LPA learned that there were items available for staff to use to conduct activities but as the Memory Care Director/Activities Director was part-time, there were usually only 1 or 2 caregivers working in Memory Care. Activities were not facilitated on a regular basis after 2:00 PM.

The above allegations were SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk to clients/residents in care.

An Exit interview was conducted with Armando Rodriguez, Designated Facility Administrator.

A copy of this report and Appeal Rights provided.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230329101714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 B
06/29/2023
Section Cited
CCR
87464(f)(4)
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CCR 87464(f)(4) Basic Services
(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed...as indicated... with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications...

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Administrator to submit a plan for meeting all residents' shower needs to kimberly.viarella@dss.ca.gov by POC due date of 06/29/2023.
Administrator to also submit written proof to the above email that residents have received showers as per shower schedule.
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This requirement was not met as evidenced by: Based on interviews and record reviews, residents did not receive showers as per recent shower schedule. Licensee did not ensure that showers took place This poses a potential health and safety risk to residents in care.
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Type B
06/29/2023
Section Cited
CCR
87625(b)
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CCR 87625(b) 1-10 Managed Incontinence ...Ensuring that residents who can benefit from scheduled toileting are assisted... Ensuring that incontinent residents are checked... Ensuring that ... residents are kept clean and dry and that the facility remains free of odors...
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Administrator to provide to submit a plan for meeting all residents' incontinent care needs to kimberly.viarella@dss.ca.gov by the POC due date of 06/29/2023.
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This requirement was not met as evidenced by: Based on interviews and observations residents have been left in wet/soiled adult briefs. Licensee did not ensure that residents were clean and that the facility remain odor free from incontinence. This poses a potential 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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230329101714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 B
06/29/2023
Section Cited
CCR
87219(a)
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CCR 87219(a) Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:...
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Licensee will submit to kimberly.viarella@dss.ca.gov an activities calendar that will include a schedule of activities that provide socialization, physical activity, mental stimulation, and opportunities to foster skills and interests by the POC date of 06/29/2023.
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This requirement was not met as evidenced by: Based on interviews, observation and record reviews, Licensee did not ensure that activities were being planned and implemented on a scheduled basis. This poses a potential health and safety risk to residents in care.
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 Licensee will also submit pictures of residents and staff participating in these scheduled activities to kimberly.viarella@dss.ca.gov.
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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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/29/2023 and conducted by Evaluator Kimberly Viarella
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230329101714

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
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Armando RodriguezTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility tables are in disrepair.
INVESTIGATION FINDINGS:
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On 06/22/2023 Licensing Program Analyst, (LPA) Kimberly Viarella visited this facility to deliver complaint findings. LPA was met by Armando Rodriguez, Designated Facility Administrator. The census at the time was 108 residents with 18 in Memory Care.

FACILITY TABLES WERE IN DISREPAIR. Based on information gathered through interviews, it was learned that Memory Care used glass table toppers. These glass table toppers rested on top of the tables in the dining area and were not anchored or attached to the tables. The tables were not in disrepair, however, they were not appropriate for Memory Care as they could have cracked, slipped, or fallen. They posed a safety risk to residents in care, however, it was also learned during the course of this investigation that these glass toppers were removed.

Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 5