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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 09/18/2023
Date Signed: 09/18/2023 06:22:32 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
04/05/2023 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20230405184401
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: 122DATE:
09/18/2023
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Valerie Pais, Director of MarketingTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Understaffed to care for residents.
Residents are not bathed.
Sheets are not clean.
INVESTIGATION FINDINGS:
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On 09/18/2023, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to continue a complaint investigation. The LPA identified herself, the purpose of the visit and asked to speak with the Designated Facility Administrator. This LPA met with Valerie Pais, the Director of Marketing and a brief interview followed.

Allegation: Residents are not bathed.

This LPA learned from interviews conducted with the designated shower workers that residents in Memory Care were not bathed as scheduled. There were 2 designated caregivers tasked with showers, personal laundry, trash, and dog walking tasks in Memory Care. Due to the fact that different residents required different types of assistance with their hygiene routine, it could take up to 40 minutes or more to shower a single resident. This LPA also learned that one shower worker had Friday and Sundays off and the other
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: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
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-20230405184401
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: 09/18/2023
NARRATIVE
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had Thursday, Friday, and Saturday off. This meant that there was no one available on Fridays to assist with showers and only 1 person on Saturday and Sunday. LPA learned during the course of the investigation that sometimes the shower staff were not able to complete all of the showers assigned to them that day. This LPA has also noted a strong smell of urine upon entering Memory Care during the tour conducted on 4/6/23.
The preponderance of the evidence has been met and this allegation has been SUBSTANTIATED. According to Title 22 of the California Code of Regulations, Division 6, Chapter 8, Basic Services 87464(f)(4). This Deficiency was cited on the LIC 9099D page.

Allegation: Sheets are not clean.

During the course of the investigation, Licensing Program Analyst (LPA) Kimberly Viarella and Licensing Program Manager (LPM) Liza King toured Memory Care. A cursory inspection of the bedding in the memory care rooms (3) found that at least one was soiled and in need of being changed. This observation, combined with additional information supplied by a responsible party interviewed, provided the preponderance of evidence needed to substantiate the above allegation.

The preponderance of the evidence has been met and this allegation has been SUBSTANTIATED. According to Title 22 of the California Code of Regulations, Division 6, Chapter 8, Personal Accommodations and Services 87307(a)(3)(C). This Deficiency was cited on the LIC 9099D page.

Allegation: Understaffed to care for residents.

This LPA interviewed 6 employees as part of this investigation; 3 staff and 3 members of management. 5 out of the 7 individuals stated that the facility was understaffed at the time of the complaint. In addition to the results of these interviews, the following event occurred on 04/06/23 when 3 LPAs made an unannounced visit to open this complaint. LPAs observed a resident (R3) in distress, talking to herself about how she couldn’t remember how to use the elevator or where to find the resident council meeting. LPAs heard her praying out loud. LPA Arielle Pascua approached R3 and said that she would find someone to help her find the meeting. When LPA Pascua went to the front desk and asked the receptionist if there was someone who could assist R3, the receptionist said, “Just push the down button and she’ll know what to do.” No staff

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230405184401
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: 09/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2023
Section Cited
CCR
87464(f)(4)
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(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...with those activities of daily living such as dressing, eating, bathing and assistance...
This requirement was not met as evidenced by:
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Licensee shall cross-train all caregivers to shower residents (eliminating "shower person") and shall implement shower sheets that RCD will check in order to hold staff accountable. Licensee will provide a schedule of in-services to train staff on showering protocols. This will be submitted to
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Based on observation, record review and interview, the licensee did not ensure that all residents were receivng their scheduled showers. This poses/posed a potential risk to the health and saety of residents in care.
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kimberly.viarella@dss.ca.gov by 09/25/2023.
Type B
09/25/2023
Section Cited
CCR
87307(a)(C)
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(a) Living accommodations and grounds shall be... (3)Equipment and supplies necessary for personal care... the licensee shall assure provision of: (C) Clean linen, including blankets... to ensure that clean linen is in use by residents at all times. This requirement was not met as evidenced by:
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Licensee shall implement sheet / bedding checks at shift change. These will be documented for 1 month beginning 09/25/23 The template for these sheet checks will be submitted to kimberly.viarella@dss.ca.gov on 09/25/23.
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Based on observation 1 out of 3 beds were found to have soiled linens an were in need of being changed.
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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: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230405184401
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: 09/18/2023
NARRATIVE
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member came to assist. At 2:00 PM LPA Pascua, escorted the resident down in the elevator and once on the ground floor, LPA was able to locate a Skyline staff member to assist the resident from there. It was also learned during the course of this investigation that there were times in the evenings in Memory Care when residents were left unsupervised because caregivers were occupied cleaning up after a resident had “explosive diarrhea.”

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. 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 Lubriderm lotion. These items were removed during the visit and facility staff were instructed by the RCD to do a check of the bedrooms, closets, and drawers for any other toxins. A citation for this deficiency was delivered that day.



Based on the above information gathered during the course of this investigation and combined with the 2 other substantiated allegations, the preponderance of evidence has been met and this allegation is SUBSTANTIATED.

According to Title 22 of the California Code of Regulations, Division 6, Personnel Requirements - General 87411(a). This Deficiency was cited on the LIC 9099D page.

A copy of this report was provided, along with Appeal Rights.
Exit interview.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20230405184401
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: 09/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2023
Section Cited
CCR
87411(a)
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 (a) Facility personnel shall...be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for 16 or more... to ensure provision of personal care and assistance... This requirement was not met as evidenced by:
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Licensee informed LPA that there have been changes in the administration and an increase in carestaff since the complaint was made. Licensee will supply the updated list of the directors and staffing departments with the number of employees in each and if they are part
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Based on interviews 5 out of 7 individuals employed at the facility felt it was understaffed to meet the needs of residents in care. Based on observations, 8 toxic items were found in 2 memory care rooms and it has been substantiated the residents are not receiving showers as scheduled.
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time or full time. This will be done for April 2023 and present. Licensee will also list open positions and what is being done to recruit for them. This information will be submitted to kimberly.viarella@dss.ca.gov by 09/25/2023.
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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: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5