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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005532
Report Date: 12/21/2023
Date Signed: 12/21/2023 12:06:14 PM


Document Has Been Signed on 12/21/2023 12:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 117DATE:
12/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Ronda Mares-Business Office ManagerTIME COMPLETED:
11:11 AM
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On 12/21/23 Licensing Program Analyst (LPA) Maja Jensen arrived unannounced to conduct a case management visit for deficiencies. LPA Jensen met with Business Office Manager Ronda Mares and explained the purpose of today's visit.

On 12/12/23 LPA Jensen conducted a pre-licensing visit in relation to a change in ownership application. During the course of the pre-licensing inspection LPA Jensen observed unsecured cleaning chemicals in resident room cabinets in the assisted living portion of the facility which included Lysol cleaner, Spray and Wash and Liquid Gold wood cleaner. The laundry room was also found to be unlocked and contained cleaning supplies for washing clothing.

LPA Jensen reviewed the resident file for Resident 1 (R1). The Physician's Report for R1 states that R1 is unable to administer their own medication, unable to administer their own injections and unable to perform their own glucose testing. LPA Jensen interviewed the medication technician on duty who advised that R1 has been administering her own insulin and performing her own glucose testing which contradicts the direction given on the Physician's Report.

Deficiencies are being cited pursuant to the California Code of Regulations, Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were given.


SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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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