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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700589
Report Date: 05/08/2023
Date Signed: 05/08/2023 03:54:52 PM

Document Has Been Signed on 05/08/2023 03:54 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: 2DATE:
05/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Marvin RodriguezTIME COMPLETED:
03:02 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Marvin and Andres explained the purpose of the visit. Later joined by Monalisa Legaspi.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 142 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees.

Fire extinguishers and Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medications. LPA reviewed 2 resident and 3 staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. During the file review LPA observed outdated physician's report for R1 (2019). R1 has a diagnosis of Dementia.

First aid kit was checked and is complete. LPA observed a carbon monoxide detectors in the facility. Fire drill was conducted on 12/2022.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2023
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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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: 05/08/2023
NARRATIVE
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All deficiencies are cited from the California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8 ; and the Health and Safety Code 1569.38 Residential Care Facilities on the LIC 809-D. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. Appeal Rights given. Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/08/2023 03:54 PM - It Cannot Be Edited


Created By: Albert Johnson On 05/08/2023 at 02:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SKYE LUIS CARE HOME
FACILITY NUMBER: 342700589

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2023
Section Cited
CCR
80088(e)(1)

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Furniture, Fixtures, Equipment, and Supplies
1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C)....
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Staff lowered the thermostat during the tour and agreed to test the hot water for 3 days. Test hot water in the bathroom to meet Title 22 regulations. Send 3 day hot water temperature to LPA.
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LPA tested hot water at 142 degrees F. Licensee failed to assure hot water meeting Title 22 regulation of 105-120 degree F. This poses a immediate health and safety risk to resident in care.
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Type B
05/19/2023
Section Cited
CCR87705(c)(5)

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(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
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Licensee agrees to submit a plan of correction to LPA by 5/19/2023 on how R1's annual appraisal will be completed.
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Based on observation, interview, and records reviewed, the licensee did not comply with the section cited above in (1) out of (1) residents diagnosed with dementia which poses a potential health and safety risk to persons 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 Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023


LIC809 (FAS) - (06/04)
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