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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005532
Report Date: 10/31/2023
Date Signed: 11/01/2023 10:30:18 AM


Document Has Been Signed on 11/01/2023 10:30 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
557005532
ADMINISTRATOR:AMIEE JO MATTSONFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 119DATE:
10/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Amiee Jo MattsonTIME COMPLETED:
02:00 PM
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On 10/31/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a case management visit. LPA was met by Facility Designated Administrator (FDA), Amiee Jo Mattson and explained the purpose of the visit.

Current census was 119. A brief interview with FDA Mattson was conducted.

The purpose of this visit is to conduct a follow up visit regarding a prior case management conducted by this LPA on 04/06/2023 when it was learned that R1 allegedly sexually abused R2.

Based on information gathered during the investigation it was found that R2 was not able to fully disclose that they were sexually abused by R1 and provide a time and location in which this incident occurred. R1 did not provide any comments towards the allegation. Additional interviews were conducted and it was found that the incidents disclosed by R2 were not consistent. A police investigation was conducted by Tuolumne County Sheriff and could not find sufficient evidence to support that R1 sexually abused R2. Throughout the investigation, it was learned that care staff have continuously documented concerns that R1 would inappropriately touch other residents between the months of January 2023-May 2023 on the facilities progress notes. A review of facility documents were conducted and it was learned that the facility reassessed the resident on 01/16/2023 noting the new behaviors. Additionally, the last assessed conducted for the resident was conducted on 04/06/2023.

Based on the information gathered today, there are no deficiencies observed during today's visit. An exit interview was conducted and a copy of this report was provided to the facility via email and electronic receipt confirms receiving these documents.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
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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