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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700589
Report Date: 04/27/2022
Date Signed: 04/27/2022 10:12:44 AM

Document Has Been Signed on 04/27/2022 10:12 AM - 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) 685-6910
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 3DATE:
04/27/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Annie Lyn RodriguezTIME COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct a quarterly case management visit due to a current stipulation order in place. The facility is licensed under a probationary license.

LPA observed the current stipulation order place in a conspicuous place in the front area of the home. The licensee has completed 10 out of 18 hours of training related to observation change in residents, duty to obtain timely medical care, prohibited health conditions and prevention of pressure injuries. The last training is scheduled to be completed on May 02, 2022. A detailed copy of training course outline and certificates was obtained for the facility file.

Licensee was reminded that all unusual incidents must be verbally informed to licensing by the next working day and a written report must be submitted within seven days of the incident.

LPA observed zero residents with prohibited health conditions.

On 03/18/2022, LPA Valerio received the licensee's written procedures for obtaining timely medical care for residents and for extended absences of the administrator. Licensee stated all staff have been trained and are aware of the procedures.

Licensee was reminded to review stipulation order to ensure all requirements are met by their deadlines.
During the visit, LPA interacted with residents. Residents were observed watching television and sitting in the front area.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with the Administrator
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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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