557005532-11-9-2021-27-AS-KHOS-C8LN37-20211109090554

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 10/11/2021
Date Signed: 11/09/2021 08:32:42 AM

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
08/12/2021 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 27-AS-20210812085114

FACILITY NAME:	SKYLINE PLACE SENIOR LIVING		FACILITY NUMBER:	557005532
ADMINISTRATOR:	STEPHANIE OLLEY		FACILITY TYPE:	740
ADDRESS:	12877 SYLVA LN		TELEPHONE:	(209) 588-0373
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY:	135	CENSUS: 108	DATE:	10/11/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Valarie Pais, Regional Sales Specialist		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Insufficient staffing to meet the residents' needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced to deliver findings on the above allegations. LPA met with Valarie Pais, Regional Sales Specialist and explained the purpose of the visit.

Regarding the allegation there is insufficient staff to meet residents needs. This investigation is based on LPA observation and staff interviews. LPA interviewed several staff at the facility. The facility staff all stated they feel residents needs are not being met such as showers, and disposing of all incontinence care due to lack of staffing. The facility does not have a current shower schedule or log at this time for LPA to review.

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

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-20210812085114

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
	VISIT DATE: 10/11/2021

NARRATIVE

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Based on observations and interviews conducted, the preponderance of evidence standards have been met, therefore, the allegation is found to be SUBSTANTIATED.

The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights was left at the facility.

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This is an amended report.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20210812085114

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: 10/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/22/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. [...] This requirement was not met as evidenced	1 2 3 4 5 6 7	Administrator will provide daily work schedules to LPA by POC date. Administrator will also provide next day updates to LPA if any staff called out, and if so who covered those shifts. Administrator will provide these updates to LPA for 14 days.
	8 9 10 11 12 13 14	During interviews LPA obtained information that residents are not receiving care and services to meet their needs timely such as scheduled showers and re ordering medications due to insufficient staffing. This causes potential safety hazard to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021

LIC9099 (FAS) - (06/04)

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