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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 02/08/2022
Date Signed: 02/10/2022 11:26:35 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
10/19/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20211019104542
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: 95DATE:
02/08/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Ilana CorpusTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility neglecting medical needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on 02/08/2022 at 11:30 a.m. to investigate a complaint on the above allegation. LPA met with Administrator Ilana Corpus and explained the purpose for today’s visit.

Regarding the alleagtion facility is neglecting medical needs. Based on interviews and records reviewed the facility had a COVID outbreak that began beginning of October 2021 and lasted though the beginning of November 2021. The facility had up to 20 COVID positive residents, and several COVID positive staff during this time. The faciliy Administrator Jacob Primeau did schedule a vaccine clinic in October but the provider cancelled due to the high number of COVID positives in the building. The facility has had two booster clinics since the outbreak. The clinics were held on 11/29/2021 and 01/31/2022. Therefore, the allegation is deemed UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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 5
Control Number 27-AS-20211019104542
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: 02/08/2022
NARRATIVE
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No deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Ilona Corpus and a copy of this report was provided.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/19/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20211019104542

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: 95DATE:
02/08/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Ilana CorpusTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Inadequate staff to meet resident needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on 02/08/2022 at 11:30 a.m. to investigate a complaint on the above allegations. LPA met with Administrator Ilana Corpus and explained the purpose for today’s visit.

Regarding the allegation facility has inadequate staff to meet residents needs. Based on interviews with facility staff and residents the facility has inadequate staff to meet needs of residents. LPA interviewed four facility staff, and two facility residents. The staff all agreed residents are not consistently showered according to the shower schedule due to lack of staffing. The staff stated residents showers are even completely skipped at times if there is not enough staff to help with showering. The staff also agreed residents are watiing long periods even more than thirty minutes at times to have incontinent needs mets. Based on this the complaint will be SUBSTANTIATED.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20211019104542
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: 02/08/2022
NARRATIVE
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The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility Administrator Ilona Corpus and a copy of this report along with appeal rights was provided
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20211019104542
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: 02/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2022
Section Cited
CCR
87464(f)(1)(c)
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87464 Basic Services(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirment has not been met as evidenced by:
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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 10 days.
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Based on interviews with 4 facility staff the licensee did not ensure there is sufficient staff to ensure all resident needs are being met including scheduled showers which poses an immediate health, safety, or personal rights risk to 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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5