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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 08/22/2023
Date Signed: 08/22/2023 12:41:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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 Ruth Wallace
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: 115DATE:
08/22/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator - Aimee Jo MattsonTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Medication is not administered timely
INVESTIGATION FINDINGS:
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On 08/24/2023 Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced complaint visit to deliver complaint finding. The LPA explained the purpose of the visit. LPA met with the new Designated Facility Administrator and interview followed.

Through interviews and a review of records, this Department learned that residents were not being administered their medications as scheduled. During the course of this investigation, this Department learned that when doses were missed, or a medication error occurred, they were reported to the Resident Care Director (RCD) who in turn, reported them to the Health and Wellness Director. Multiple sources, (S1 and S2) stated that medication errors occurred during the time frame that the above allegation was made, confirming that medications were not administered timely. Upon a review of 4 resident files, it was observed that 2 out of 4 residents were not provided medications as prescribed. Resident 1 (R1) went without one of their daily medications from 05/28/2023 – 06/14/2023. Resident 2 (R2) was prescribed a medication that was supposed to be administered for a certain number of consecutive days; a review of the records revealed that this was not done. Based on observation, a review of records, and through information gathered through interviews, the above allegation was SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegation occurred as alleged.

The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. Immediate civil penalty of $1,000.00 is being assessed for repeat violation within one year. Facility was cited on February 10, 2023 for 87465(c)(2).
Failure to correct the deficiency may result in additional civil penalties.
Exit interview with administrator. A copy of this report and Appeal Rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
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 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
CCLD Regional Office, 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: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2023
Section Cited
CCR
87465(c)(2)
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87465(c)(2): Incidental Medical and Dental Care:(c) ...provided all of the following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement was not met as evidence by:
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The Licensee agrees to submit a plan of when additional in-service training regarding the section 87465(c)(2) will be conducted. A statement of correction will be submitted by plan of correction date of 8/23/203 via email to LPA Kim Viarella. Proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to LPA Kim Viarella after training is finished.
kim.viarella@dss.ca.gov
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Based on LPA documentation and interviews, the Facility did not comply with the section cited in 87465(c)(2). Upon a review of 4 resident files, it was observed that 2 out of 4 residents were not provided medications as prescribed. Resident 1 (R1) went without one of their daily medications from 05/28/2023 – 06/14/2023. This poses an immediate health and safety risk to clients in care.
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Immediate civil penalty of $1,000.00 is being assessed for repeat violation within one year. Facility was cited on February 10, 2023 for 87465(c)(2).
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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: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2