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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 557005532
Report Date: 03/17/2022
Date Signed: 03/18/2022 03:23:08 PM

Substantiated


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
11/16/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20211116120025
FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
557005532
ADMINISTRATOR:ILONA ROZA CORPUSFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 112DATE:
03/17/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Ilona CorpusTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Residents do not receive assistance with bathing
Staff do not communicate with residents, nor authorized representatives promptly and appropriately
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on March 17, 2022 at 2:00 p.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 staff do not communicate with residents, nor authorized representatives promptly and appropriately based on interviews with resident responsible parties the facility did not effectively communicate to them resident’s health conditions. The responsible party for Resident 1 stated she was updated regarding her mother’s condition mainly through speaking with her mother. Resident 1's responsible party stated the staff would speak to her when she would call the facility but facility staff never initiated communication with her. Resident 2’s responsible party stated he was never given updates on his mothers health by the facility. Resident 2's responsible party stated he would have to call the facility when his mother would report to him her meals were not being delivered or any other concerns he needed addressed. Therefore, this allegation is 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: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
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-20211116120025
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: 03/17/2022
NARRATIVE
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Continued from 9099..

Regarding the allegation residents do not receive assistance with bathing. This complaint was SUBSTANTIATED on 02/08/2022 complaint # 27-AS-20211019104542. 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. Therefore, this complaint is SUBSTANTIATED. The facility was cited and a civil penalty was issued for repeat violations on 02/08/2022. There will be no further citations issued at this time.

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: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 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
11/16/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20211116120025

FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
557005532
ADMINISTRATOR:ILONA ROZA CORPUSFACILITY TYPE:
740
ADDRESS:12877 SYLVA LNTELEPHONE:
(209) 588-0373
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 112DATE:
03/17/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Ilona Corpus TIME COMPLETED:
05:45 PM
ALLEGATION(S):
1
2
3
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5
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9
Residents are not allowed visitors
Residents do not receive assistance with grooming
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt arrived at the facility unannounced on March 17, 2022 at 2:00 p.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 residents do not receive assistance with grooming. LPA spoke with 3 facility residents who all stated they either do not need assistance with grooming or they were unable to clearly state if they were assisted with grooming needs. LPA spoke with 3 resident responsible partied. Resident 1’s responsible party stated her mother did not want to be bothered with grooming during the time she was COVID positive. Resident 2’s responsible stated his mother is independent and did not need much grooming assistance. Resident 3’s responsible party stated his mother was only cared for by the hospital during the time she was COVID positive. 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: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
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 2
Control Number 27-AS-20211116120025
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: 03/17/2022
NARRATIVE
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Continued from 9099A....

Regarding the allegation residents are not allowed visitors. Based on records reviewed by LPA from state licensing, and documents sent to responsible parties from the Administrator the facility did appear to be following COVID visitation guidelines. Therefore, this complaint is 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.

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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20211116120025
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: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2022
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities (a)(8)To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. The following requirement has not been evidenced by:
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Administrator will conduct training on effective communication with facility staff by 03/22/2022 POC date.
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 Based on interviews with responsible parties the facility did not properly communicate the health condition of the residents to the responsible parties which poses a potential 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: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5