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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:30:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2023 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20231206163939
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:0CENSUS: 115DATE:
02/15/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ronda MaresTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility staff did not issue refund to resident's responsible party upon resident's death.
INVESTIGATION FINDINGS:
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On 2/15/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegations. LPA Jensen met with the Business Office Manager, Ronda Mares, and explained the purpose of the visit. LPA Jensen also spoke to Executive Director Aimee Jo Mattson by telephone and explained the purpose of today's visit.

LPA Jensen reviewed Statement of Account ledgers for resident 1 (R1). The ledgers show that there were separate monthly charges for the unit R1 occupied and the services that R1 received. The statement of account shows that R1 was billed for the unit occupied until R1's personal belongings were removed which was 16 days after R1's death as is permissible by the Health and Safety Code. R1 was also billed for services for 16 days after R1's death or through the time personal belongings were removed. Services should have ceased being billed upon R1's death therefore the allegation of "facility staff did not issue refund to resident's responsible party upon resident's death" is SUBSTANTIATED. Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
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 3
Control Number 27-AS-20231206163939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 557005532
VISIT DATE: 02/15/2024
NARRATIVE
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LPA Jensen discussed the partial refund owed with the Business Office Manager and a credit was issued during the course of this visit.

A deficiency is being cited pursuant to the Health and Safety Code (HSC). An exit interview was conducted and a copy of this report, a confidential names list and appeal rights were provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20231206163939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 557005532
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/15/2024
Section Cited
HSC
1569.652(c)
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A refund of any fees paid in advance ... shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate...This requirement was not met as evidenced by:
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No plan of correction is required as the service fees in question were credited in the presence of the LPA during the course of this visit.
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Based on the records reviewed the resident was billed for receiving services for 16 days after the date of death, in addition to being billed for room charges. This poses a potential risk to the health, safetya nd personal rights of residents in care.
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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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: (916) 639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3