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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700589
Report Date: 04/24/2024
Date Signed: 04/24/2024 02:07:21 PM

Document Has Been Signed on 04/24/2024 02:07 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SKYE LUIS CARE HOMEFACILITY NUMBER:
342700589
ADMINISTRATOR/
DIRECTOR:
RODRIGUEZ, ANNIE LYNFACILITY TYPE:
740
ADDRESS:8705 GREAT CTTELEPHONE:
(916) 685-6910
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 5DATE:
04/24/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Annie Lyn RodriguezTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 4/24/24, at 10:45am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct their quarterly case management visit. LPA met with the facility administrator, Annie Lyn Rodriguez and explained the purpose of the visit. During today's visit, 4 residents in care were present with 2 staff on duty. Facility is approved for 6 non-ambulatory elderly residents, fire cleared for 1 bedridden resident, and approved for 1 hospice resident.

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

LPA toured the physical plant of the facility. During this visit, all residents were in their bedrooms. 4 of 5 resident bedrooms were observed to be cleaned and free of obstruction. One resident bedroom was not observed due to resident sleeping during the tour. The room temperature was observed to be at 71 degrees F. All 3 bathrooms were observed to be clean and free of clutter. Hot water temperature in the hallway bathroom was measured at 114 degree F. During the tour of the kitchen, LPA observed 2 resident medications were stored in the kitchen refrigerator, which are unlocked and accessible to resident in care. LPA observed the administrator, Annie Lyn Rodriguez, immediately placed the medications in a small refrigerator and placed it in a locked room marked "staff room" in the kitchen area. Other medications are located at the office area and were observed to be properly stored, locked and inaccessible to resident in care. A technical advisory was also provided to the administrator to obtain and place a thermometer inside the freezer and refrigerator to ensure regulatory temperature is maintained at all times.

Con't to LIC809
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 HOME
FACILITY NUMBER: 342700589
VISIT DATE: 04/24/2024
NARRATIVE
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The outdoor area was observed be free of clutter and obstructions. There is a freezer outside the covered patio at the back area of the facility. LPA observed the side gate, located at the right side of the facility, to not work properly as the bottom is stuck on the ground and LPA used a bit of force to open the gate. Technical advisory was provided to the administrator to repair the issue. The back storage was observed to be unlocked. Inside the storage, LPA did not observed sharp or dangerous objects. However, technical advisory was still provided to the administrator to lock the storage as a precaution.

Through resident file review, it was discovered that 2 of 5 residents' LIC 602A was signed by nurse practitioners, in place of physicians. Technical advisory was provided to the administrator to submit a waiver request for non-physicians to sign residents' medical assessments and prescriptions. LPA reviewed 3 staff files. All 3 staff have current 1st aid/CPR certificates. Monthly training as per stipulation is conducted on a monthly basis. Last training was conducted on 3/4/2024.

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.
Exit interview conducted with Annie Lyn Rodriguez and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2024 02:07 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 04/24/2024 at 01:39 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYE LUIS CARE HOME

FACILITY NUMBER: 342700589

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2024
Section Cited
CCR
87465(h)(2)

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87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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Corrected during this visit. Adminstrator placed the 2 medications inside a small refridgerator and placed it inside a locked room.
Administrator to submit a statement of understanding of the regulation, CCR Section 87465 to the Department by the POC due date of 4/25/2024.
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Based on observation, the licensee did not comply with the regulation cited above. LPA observed 2 resident medications were stored in the kitchen refrigerator and are accessible to residents in care which poses an immediate health, safety and personal risks to residents in care.
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Administrator to conduct a staff training on the subject of properly storing medications and submit a proof of completed training to the Department by 5/1/2024.

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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:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024


LIC809 (FAS) - (06/04)
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