557005532-3-4-2022-27-AS-KHOS-CCTS58-20220324133356

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 03/03/2022
Date Signed: 03/04/2022 07:13:56 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
02/28/2022 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 27-AS-20220228143448

FACILITY NAME:	SKYLINE PLACE SENIOR LIVING		FACILITY NUMBER:	557005532
ADMINISTRATOR:	ILONA ROZA CORPUS		FACILITY TYPE:	740
ADDRESS:	12877 SYLVA LN		TELEPHONE:	(209) 588-0373
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY:	135	CENSUS: 100	DATE:	03/03/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator, Ilana Corpus		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Faciliy has an infestation of ants

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on 03/03/2022 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 an infestation of ants. Based on LPA observation, and staff interview the facility is not currently infested with ants. Resident 1 noticed ants near his sink, and trash area where he disposes of food waste. Administrator stated during interviews once staff noticed the ants the area was immediately sprayed. Resident 1's trash is now disposed of every night, and ant bait traps have been set out by maintnence. LPA went into Resident 1's room and did not see any ants near the sink or any other area.
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 Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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-20220228143448

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: 03/03/2022

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	No deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility Administrator and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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
02/28/2022 and conducted by Evaluator Sarah Hurt

COMPLAINT CONTROL NUMBER: 27-AS-20220228143448

FACILITY NAME:	SKYLINE PLACE SENIOR LIVING		FACILITY NUMBER:	557005532
ADMINISTRATOR:	ILONA ROZA CORPUS		FACILITY TYPE:	740
ADDRESS:	12877 SYLVA LN		TELEPHONE:	(209) 588-0373
CITY:	SONORA	STATE: CA	ZIP CODE:	95370
CAPACITY:	135	CENSUS: 100	DATE:	03/03/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator, Ilana Corpus		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not wnsure residents are adequately fed
Staff mismanaging resident medications

INVESTIGATION FINDINGS:

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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: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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-20220228143448

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: 03/03/2022

NARRATIVE

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Regarding the allegation staff mismanaging resident medications. Based on records reviewed and staff interviews Staff 1 stated the pharmacy was notified when Resident 1 had 6 pills left of his pain medication left in the bottle. Resident 1 ran out of medication on 02/23/2022. Staff 1 stated the pharmacy was unable to get an approval from the emergency room doctor. Staff 1 stated the correct number for the doctor was not being faxed and when they finally sent it to the correct number the doctor asked that Resident 1 be seen before given any further refills. Resident 1 was taken his appointment and given refills of the medication on 02/28/2022. Resident 1 did not have his medication for 5 days. Based on this the complaint is SUBSTANTIATED.

The following deficiency was 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 along with appeal rights was provided.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah Hurt	TELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20220228143448

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: 03/03/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/04/2022 Section Cited CCR 87464(4)	1 2 3 4 5 6 7	87464 (4) Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications. The following has not been met as evidenced by:	1 2 3 4 5 6 7	Administrator will conduct training for medication technicians on timely medication refills by 03/05/2022 POC date.
	8 9 10 11 12 13 14	Based on interviews with staff Resident 1 went without his medication for 5 days which posses an immediate risk to health, safety or personal rights to residents in care.	8 9 10 11 12 13 14
Type B 03/08/2022 Section Cited CCR 87555(b)(1)	1 2 3 4 5 6 7	87555(b)(1)General Food Service Requirements (1)Where all food is provided by the facility arrangements shall be made so that each resident has available at least three meals per day. Exceptions may be allowed on weekends and holidays providing the total daily food needs are met. Not more than fifteen (15) hours shall elapse between the third and first meal.	1 2 3 4 5 6 7	Administrator will train facility kitchen staff on general food service requirements by 03/08/2022 POC date.
	8 9 10 11 12 13 14	The following has not been met as evidenced by: Based on staff interview Resident 1 was not served breakfast recently until 11:00 a.m. This poses a potentiol health, safety, or personal rights risk to residents in care.	8 9 10 11 12 13 14

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: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5