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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701097
Report Date: 09/01/2023
Date Signed: 09/01/2023 11:31:50 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230802083802
FACILITY NAME:SKYPARK MANORFACILITY NUMBER:
342701097
ADMINISTRATOR:RICHARDSON, SHERRYFACILITY TYPE:
740
ADDRESS:5510 SKY PARKWAYTELEPHONE:
(916) 422-5650
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:144CENSUS: 89DATE:
09/01/2023
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Rabindar Singh and Susan McClureTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff failed to treat resident with dignity and respect

INVESTIGATION FINDINGS:
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On 09/01/2023 at 10:55 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at this facility to conduct a complaint visit. LPA met with Business Office Manager, Rabindar Signhand and Dietary Director/Assistant Administrator, Susan Mclure and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. Throughout the course of this investigation, the Department conducted interviews, reviewed facility files, and reviewed medical documents.

Allegation: Staff failed to treat residents with dignity and respect
It was alleged that the facility staff failed to treat resident with dignity and respect. LPA Lee interviewed 10 out of 10 residents. It was learned that 6 out of 10 residents had concerns regarding facility staff not treating residents with dignity and respect. 6 out of 10 resident stated that facility staff walks into resident's room without knocking and turns on the light and never turn off the light and shut the door when facility staff leave residents room.

Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20230802083802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
87468.1(a)
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87468.1(a) Personal Rights of Residents in All Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:

This requirement is not met as evidenced by:
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Licensee shall provide an in-service to all staff regarding personal rights. Licensee will email LPA Lee at pang.lee@dss.ca.gov the in service training documents and signature of staff who attended the training with sign in sheet by POC due date 09/15/2023 by 5:00 PM by end of day.
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Based on interviews conducted, licensee did not ensure that resident are treated with respect and dignity. Based on interview, It was learned that 6 out of 10 residents had concerns regarding facility staff not treating residents with dignity and respect. 6 out of 10 resident stated that facility staff walk into resident's room without knocking and turns on the light and never turn off the light and shut the door when facility staff leave residents room. This poses a potential health, and safety risk to residents 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20230802083802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SKYPARK MANOR
FACILITY NUMBER: 342701097
VISIT DATE: 09/01/2023
NARRATIVE
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 6 out of 10 resident shared that facility staff interrupt residents when residents are talking to other staff. LPA Lee interviewed 10 out of 10 facility staff and 10 out 10 facility staff denies that facility failed to treat residents with dignity and respect.

As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of the 9099 report, 9099-D page, and appeals right document were provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3