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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700589
Report Date: 01/10/2024
Date Signed: 01/10/2024 12:23:54 PM

Document Has Been Signed on 01/10/2024 12:23 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
01/10/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Annie Lyn Rodriguez, AdministratorTIME COMPLETED:
12:30 PM
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On 1/10/2024, at 10:30am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a quarterly case management visit. LPA Villanueva met with Administrator on record Annie Rodriguez and explained the purpose of the visit. During this visit, LPA observed 2 resident in care with 2 staff on duty. LPA observed the current stipulation order place in a conspicuous place in the front area of the home at the office desk.

LPA and Administrator Annie toured the facility to ensure compliance with Title 22 regulations. LPA observed 1 resident in care who was watching TV and 1 resident was napping. Two bedrooms are currently being occupied. The facility has an approved hospice waiver for 1, and there is currently no resident on hospice or bedridden. Common areas and resident bedrooms were observed to be clean, organized, and free from obstructions. Facility was observed to have emergency water and a fully stocked pantry. Room temperature was observed at 76 degrees F. Hot water temperature was measured at 112 degree F.

Staff working in the home were observed to be fingerprint cleared. LPA observed staff trainings from June 2023 to December 2023 with topics that align with the stipulation order. LPA also reviewed 4 staff files and 2 resident files. Technical advisory was provided to the administrator to obtain PRN authorization letter from the residents' physician. 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. LPA also reviewed current LIC308.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with Annie Lyn Rodriguez, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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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