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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700589
Report Date: 07/24/2024
Date Signed: 07/24/2024 12:22:54 PM

Document Has Been Signed on 07/24/2024 12:22 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: 4DATE:
07/24/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:09 AM
MET WITH:Annie Lyn RodriguezTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 7/24/24, at 10:09am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct their quarterly case management visit due to a current stipulation order in place. The facility is licensed under a probationary license.. LPA met with the facility administrator, Annie Lyn Rodriguez and stated the purpose of the visit. Present in today's visit were 3 residents in care with 2 staff on duty.

At 11am, LPA conducted a physical inspection of the facility. Facility is approved for 6 non-ambulatory elderly residents, fire cleared for 1 bedridden resident, and approved for 1 hospice resident. LPA observed residents were in their bedroom watching TV and being assisted by staff. Room temperature was measured at 72*F and hot water temperature was measured at 114*F in 1 of 3 resident bathrooms. Bedrooms were observed to be clean and good repair. Bathrooms were observed to be maintained and good repair. Medications, sharp objects and toxic chemicals were observed to be locked and inaccessible to residents in care. Fence at the right side of the facility was observed to be leaning. Discussion with administrator Annie Lyn Rodriguez to have a plan in place to repair the fence as soon as possible. At this time, the condition of the fence is not posing health and safety risks to residents and staff.

LPA conducted review of 3 staff and 4 resident records. 3 of 3 staff reviewed have current 1st Aid/CPR certificate. 1 of 4 resident files reviewed need to update their Physician Report (dated 6/6/23). Discussion with Annie Lyn to obtain current medical assessment for 1 of 4 residents as required. LPA reviewed 2 of 4 resident medications and are in compliance at this time.



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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 07/24/2024
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Per review of the stipulation order:
Current Respondents operate in strict compliance with the regulations and statues governing RCFE?
  • Facility was observed to be in compliance during this visit.
Is there full compliance with the regulations and statues governing RCFE?
  • Facility was observed to be in compliance during this visit. Stay of exclusion is valid only for the conduct identified in the second amended accusation and second amended statement of issues.
  • Facility was observed to be in compliance during this visit.
Stay of exclusion is valid for respondent Annie Lyn Rodriguez association to facility 1 & 2.
  • Facility was observed to be in compliance during this visit.
Respondent completed 18 hrs. of training after 90 days of this Stipulation?
  • Annie Lyn has completed 18 of 18 hours of training.
Stipulation is posted in a conspicuous place.
  • Stipulation order was observed to be posted at the office area near the entrance.
Has there been incidents to report recently?
  • Recent incidents has occurred and report to be submitted and still within reporting requirements. Advisory was provided to Annie Lyn to ensure verbal reporting of incidents need to be done within the next day of the incident either via phone or email.
Respondent cannot retain residents who have prohibited conditions.
  • Annie Lyn has not retained nor accepted residents with prohibited conditions at this time.
Within 30 days of this stipulation, respondent have a written plan for obtaining timely medical care for residents? Have training of all staff on procedures?
  • Per review of previous visits, Annie Lyn has submitted a written plan.
Within 30 days of this stipulation, respondent have plan in place to for extended absences of the administrator on record? Have training for staff on procedures?
  • Per review of previous visits, Annie Lyn has submitted a written plan.
Monthly training of staff provided?
  • Per document review, monthly training was being conducted. Last monthly training was conducted on 6/20/24.
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.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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