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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800227
Report Date: 03/13/2026
Date Signed: 03/13/2026 03:29:32 PM

Document Has Been Signed on 03/13/2026 03:29 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SKYLINE VILLAFACILITY NUMBER:
361800227
ADMINISTRATOR/
DIRECTOR:		MARTHA RAMOSFACILITY TYPE:
740
ADDRESS:20276 MAJESTIC DRTELEPHONE:
(760) 240-0730
CITY:APPLE VALLEYSTATE: CAZIP CODE:
92308
CAPACITY: 8CENSUS: 8DATE:
03/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Martha RamosTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met Administrator, Martha Ramos and discussed the purpose for the visit. The facility is a Residential Care Facility for Elderly (RCFE) with a license capacity of (8), and a current census of (8). LPA conducted a general inspection of facility, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor space for resident activities. Outdoor activity space is shaded and enclosed with latching gates. The facility is maintained at a temperature of 71 degrees Fahrenheit. Resident bedrooms were furnished with beds, night stands, chairs, bed linen and lighting. Resident bathrooms were maintained clean and fixtures were operating properly. The hot water temperatures in the bathrooms measured at 105 degrees Fahrenheit. The facility is equipped with operating smoke/carbon monoxide alarms, fully charged fire extinguishers, laundry equipment, Library room with reading material, emergency supplies/water and telephone service. The facility has posted in a common area Community Care Licensing complaint poster, Ombudsman poster, facility license, facility sketch, emergency plan and telephone numbers. The facility has a designated area for resident and staff files. Sharps and chemicals were stored locked. The Administrator was informed that facility's annual licensing fee is due April 13, 2026.

Food Service: Kitchen and dining areas were maintained cleaned. Non-perishable and perishable food supply was sufficient for number of residents in care. Cups, plates, and utensils were sufficient for residents in care.

**continued on LIC809-C**

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2026
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 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SKYLINE VILLA
FACILITY NUMBER: 361800227
VISIT DATE: 03/13/2026
NARRATIVE
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Health Related Services: The facility maintains a first aid kit with manual and medications were centrally stored in a locked area. LPA audited medications for four (4) residents. LPA observed resident #2 (R2s) pain medication was stored in a plastic bag. The Administrator stated that the family may have brought the medication in the bag. LPA observed in R2's medication box, an expired (November 2025) over the counter medication which was listed on (R2s) medication list as current and being provided to R2. LPA showed the bottle to the Administer and asked if more of the medication was stored at the facility since the medication was expired. The Administrator stated they did not.

Record Review: Resident files were reviewed for admissions agreements, physician’s reports, appraisals, needs and services plans. LPA observed resident#1 (R1) did not have a hospice care plan at the facility for review.

Staff files were reviewed for First Aid/CPR certifications, criminal record clearances, training, and health screenings. LPA observed that no documentation staff#1 (S1) and staff#2 (S2) Hospice Care training on file for review. The facility currently has residents receiving hospice care. LPA observed (S1) did not have documentation of medication administration training on file for review. The Administrator confirmed that S1 does assist with administering medications. The facility did not maintain current liability insurance and current disaster drill staff training on file for review.

During today's visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted where this report was discussed and a copy provided with appeal rights to Administrator Ramos

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 03/13/2026 03:29 PM - It Cannot Be Edited


Created By: Magda Malcore On 03/13/2026 at 01:05 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SKYLINE VILLA
FACILITY NUMBER: 361800227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not maintaining current liability insurance for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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The Licensee/Administrator shall provide to the licensing agency a copy of facility's current insurance by POC due date.
Type B
Section Cited
CCR
87465(c)(1)
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1)There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by staff administering expired (November 2025) over the counter medication to resident #2 (R2) which was listed on resident medication list as current medication; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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The Licensee shall provide medication administration training to all staff assisting/administering resident medications and submit documentation of training to the licensing agency by POC due date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/13/2026 03:29 PM - It Cannot Be Edited


Created By: Magda Malcore On 03/13/2026 at 01:05 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SKYLINE VILLA
FACILITY NUMBER: 361800227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)(2)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (2) Four hours of training thereafter of in-service training per year on the subject of serving those residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply by not maintaining record of staff#1 (S1) and staff#2 (S2) Hospice Care training on file for review. The facility has residents receiving hospice care; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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The Licensee/Administrator shall provide documentation of staff hospice training to the licensing agency by POC due date.
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by staff #1 (S1) assisting with administering resident medication and not having documentation of medication administration training on file for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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The Licensee/Administrator shall provide documentation of S1's medication management training to the licensing agency by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 03/13/2026 03:29 PM - It Cannot Be Edited


Created By: Magda Malcore On 03/13/2026 at 01:05 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SKYLINE VILLA
FACILITY NUMBER: 361800227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by storing resident #2 (R2s) pain medication in a plastic bag; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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The Licensee shall provide medication administration training to all staff assisting/administering resident medications and submit documentation of training to the licensing agency by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above by not maintaining documentation of current emergency drill staff training for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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The Licensee/Administrator shall provide to the licensing agency documentation of emergency drill staff training by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 03/13/2026 03:29 PM - It Cannot Be Edited


Created By: Magda Malcore On 03/13/2026 at 01:05 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SKYLINE VILLA
FACILITY NUMBER: 361800227

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by storing and not properly disposing of resident expired medications. Expired over the counter medication supplement was stored with resident #2 (R2) current medication; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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2
3
4
The Licensee shall provide medication administration training to all staff assisting/administering resident medications and submit documentation of training to the licensing agency by POC due date.
Type B
Section Cited
CCR
87633(b)(4)
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (4) A description of the licensee's area of responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident's physician, and the resident's responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on LPA observations, the licensee did not comply with the section cited above by not maintaining a current and complete hospice care plan for resident #1 (R1) for review; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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2
3
4
The Licensee/Administrator shall provide to the licensing agency documentation of R1's hospice care plan by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2026


LIC809 (FAS) - (06/04)
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