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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 05/24/2023
Date Signed: 09/19/2023 09:16:16 AM

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
PUBLIC
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: 99DATE:
05/24/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Mark Crowder, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Understaffed to care for Residents
Medication is not administered timely
Residents are not bathed
Sheets are not clean
INVESTIGATION FINDINGS:
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Unannounced complaint visit was conducted on 05/24/23 by Licensing Program Analysts (LPAs) Kimberly Viarella and Charlie Yang to this facility. LPAs were met by Designated Facility Administrator, Mark Crowder, and a brief interview followed.

Current census was 99 residents.

Staff interviews were conducted pertaining to allegations above.

LPAs requested the following information:

Shower schedule for assisted living and memory care, January - March 2023
LIC 500 - Schedule for the Shower / Laundry / Dog walker / Trash workers, January - March 2023
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
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 2
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: 05/24/2023
NARRATIVE
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LIC 500 - Care Staff and Med Tech Schedule for January - March 2023
LIC 500 - Housekeeping schedule, January - March 2023

This complaint NEEDS FURTHER INVESTIGATION.

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

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2