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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 557005532
Report Date: 11/01/2021
Date Signed: 11/19/2021 03:02:36 PM

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:JACOB PRIMEAUFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 97DATE:
11/01/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jacob Primeau, Executive DirectorTIME COMPLETED:
12:00 PM
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An office meeting was conducted today in the Sacramento Regional Office via Microsoft Teams. The purpose of this meeting was to HAI recommendations for COVID mitigation and to get an update regarding staffing concerns. Present at the meeting were Regional Manager (RM) Krystall Moore, Licensing Program Manager Stephenie Doub, Shantala Ahanya, CDPH HAI, Jacob Primeau facility Administrator, Don Anderson CEO, Ginger Tarabochia, Roz Watson and Mark Weister representatives of Milestone Retirement Company.
Recommendations discussed:
  • Screening of residents with COVID and under observation
  • Use of oximeter in screening residents
  • Training of staff, donning and doffing, use of oximeter
  • Fit testing of all staff
  • Cohorting of resident
  • use of local lab for faster results
  • need to relay accurate information during daily calls
The facility agreed to do the following:
  • have a certified administrator at the facility 40 hours per week
  • have all staff fit tested by the end of the week 11/5/2021
  • all staff will receive training of donning and doffing by 11/5/2021
  • facility will conduct random spot checks of staff in donning and doffing ongoing
  • updates to the mitigation plan regarding use of oximeter and screening of residents will be provided by close of business 11/2/2021
  • licensee agreed to implement these mitigation practices at all of their communities.

No deficiencies cited during this visit. An exit interview was conducted with Executive Director Jacob Primeau and a copy of this report was provided via email. Confirmation read receipt confirms receipt of the report.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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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