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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700589
Report Date: 08/10/2021
Date Signed: 08/10/2021 03:07:09 PM

Document Has Been Signed on 08/10/2021 03:07 PM - It Cannot Be Edited

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:SKYE LUIS CARE HOMEFACILITY NUMBER:
342700589
ADMINISTRATOR:RODRIGUEZ, ANNIE LYNFACILITY TYPE:
740
ADDRESS:8705 GREAT CTTELEPHONE:
(916) 914-5119
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 3DATE:
08/10/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Annie Lyn RodriguezTIME COMPLETED:
02:45 PM
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On 08/10/21 at 1:00 PM, a Non-Compliance Conference was conducted on this day in the Sacramento South Regional Office via Microsoft Teams, due to COVID 19 precautions. The purpose of this Non-Compliance Conference meeting was to discuss the citations that has been issued in the last 24 months. Present in the meeting was Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Christina Valerio, Licensing Program Analyst (LPA) Victoria Brown, Licensee/Administrator Annie Lyn Rodriguez, Designated Administrator Monalisa Legaspi Silaean, Long Term Ombudsman Sergio Landeros, and Licensee’s Legal Representative from Simas and Associates LTD Ryan Keever. The Non-Compliance Conference process was explained during this meeting to include the Administrative Process.

5M CARE HOME, LLC, has been cited four type A deficiencies within the last three years. The facility was cited for the following issues Observation of Clients, Prohibited Health Conditions - Healing Wounds, Admission Agreement, Reporting Requirements, and Incidental Medical and Dental Care Services.

Issues discussed during the meeting were:
· The complaint filed against this facility since licensure
· Incidental Medical and Dental Care Services/Observation of Resident
· Prohibited Health Conditions – Healing Wounds
· Admission Agreement
· Reporting Requirements




Continued on LIC 809-C... Page 1 of 2
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SKYE LUIS CARE HOME
FACILITY NUMBER: 342700589
VISIT DATE: 08/10/2021
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Continued from LIC 809...

The facility has stated they will do the following to achieve continued and substantial compliance:
  • Incidental Medical and Dental Services

    • - Licensee has implemented Daily Skin Integrity Logs. Staff check the resident’s skin two times per day, once in the morning and once at night, note their observations on the log, and sign their name next to the observations on the log.
    - Licensee has implemented Daily Repositioning Logs. For any residents that require repositioning, facility staff will reposition the resident every two hours, which will be documented and signed by the staff when the act of repositioning the resident occurs.
  • Prohibited Health Conditions

    • - Licensee informed the Department that they will not accept individuals with a stage 3 or 4 wounds, or any hospice residents without an exception.
    - If current resident develops pressure wounds, the licensee stated they will monitor the wound closely and ensure care is provided according to Physician’s Orders. If the pressure wounds become stage 3 or stage 4 pressure wounds, the licensee will transport the resident to a higher level of care immediately. The licensee will have resident in care unless wounds are no longer a stage 3 or stage 4 or the Department has granted and issued an exception for the resident.
  • Reporting requirement

    • - Licensee stated she reports incidents immediately after the incident occurs
  • Admission Agreement

    • - The licensee has implemented a change to their Admission Agreement and will continue to ensure Admission Agreement is linear with Title 22 Regulations.
    - The licensee has implemented a Resident Admission Packet Checklist Procedure to ensure the Admission Packet is filled entirely and documents are not missing.
  • Technical Support Program

    • - The licensee has agreed to take part in the Department’s Technical Assistance Program.




Page 2 of 3....
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SKYE LUIS CARE HOME
FACILITY NUMBER: 342700589
VISIT DATE: 08/10/2021
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Continued from LIC 809- C page 2....

CCLD will do the following:
· Increase Monitoring
· Technical Support Program

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit. An exit interview was conducted with Administrator Annie Lyn Rodriguez. A copy of this report was provided via email and an electronic email read receipt confirms receiving these documents. Administrator Annie will sign the document and send signed copy to LPA Valerio at christina.valerio@dss.ca.gov.















Page 3 of 3.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3