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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700589
Report Date: 08/08/2022
Date Signed: 08/08/2022 02:54:00 PM

Document Has Been Signed on 08/08/2022 02:54 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) 685-6910
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: DATE:
08/08/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Bida DeVeraTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a quarterly health and safety case management visit. LPA Valerio met with facility staff and explained the purpose of the visit. Staff confirmed there are 0 residents or staff that have displayed any signs or symptoms of COVID-19 in the last 10 days. Administrator Annie was called via phone by staff. Administrator gave staff permission to sign on her behalf.

LPA observed the current stipulation order place in a conspicuous place in the front area of the home.

LPA reviewed training files for all staff. The licensee/administrator has completed 18 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. All staff working in the home were observed to be fingerprint cleared. Staff have updated 2022 training that align with the stipulation order.

LPA observed 3 residents and 2 staff during the visit. Two residents were in the living room and one in their room. LPA observed staff interactions with residents to be friendly and supportive. Residents were observed to be cheerful and relaxed.

The home was observed to be clean, organized, and free from obstructions. Facility had a 30-day supply of PPE and fully stocked fridge and pantry with non-perishables and perishables.

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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
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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