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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552701305
Report Date: 10/23/2024
Date Signed: 10/23/2024 04:42:32 PM

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
08/07/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240807163148
FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
552701305
ADMINISTRATOR:MATTSON, AIMEE JOFACILITY TYPE:
740
ADDRESS:12877 SYLVA LANETELEPHONE:
(209) 288-4630
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Valerie PaisTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff do not ensure call signal system requests are answered in a timely manner
INVESTIGATION FINDINGS:
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On 10/23/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue an investigation in to a complaint investigation related to the above listed allegations. LPA Jensen met with Executive Director Valerie Pais and explained the purpose of today's visit.

During the course of the investigation LPA Jensen reviewed care response logs and emails between the responsible party for resident 1 (R1) and facility staff. During the course of an interview with the Executive Director, LPA Jensen asked what a reasonable amount of time would be for staff to respond to a resident that activates their call pendant. The Executive Director responded that response times can vary depending on what else is happening in the facility such as a resident emergency for example but generally a call should be responded to within 15-20 minutes. LPA Jensen reviewed response logs for R1 for the week of 7/21/24 to 7/27/24. During that period of time R1 activated the call pendant 16 times and 11 of 16 times the response took more than 20 minutes.
Continued on LIC 9099C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
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 5
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
08/07/2024 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20240807163148

FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
552701305
ADMINISTRATOR:MATTSON, AIMEE JOFACILITY TYPE:
740
ADDRESS:12877 SYLVA LANETELEPHONE:
(209) 288-4630
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: DATE:
10/23/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Valerie PaisTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff did not ensure medications were dispensed as prescribed
Staff did not ensure residents incontinence care needs were being met
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
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9
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11
12
13
On 10/23/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue an investigation in to a complaint investigation related to teh above listed allegations. LPA Jensen met with Executive Director Valerie Pais and explained the purpose of today's visit.

Allegation 1: Staff did not ensure medications were dispensed as prescribed
During the course of the investigation LPA Jensen reviewed the following records:
Complete Medication Administration Record for Resident 1 (R1)
Training policy for care staff
Needs and Service Plan for R1
Pre-placement appraisal(s) for R1
Care notes/charting notes
Pharmacy consent and communication forms
email communications
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240807163148
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: SKYLINE PLACE SENIOR LIVING
FACILITY NUMBER: 552701305
VISIT DATE: 10/23/2024
NARRATIVE
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LPA Jensen also conducted an interview with the Executive Director. The Executive Director explained that the facility did not have a physician's order for one of resident 1 (R1's) medications upon move in. In addition there was confusion regarding who would administer the medication. R1's family wanted R1 to self administer medication however R1 was unable to do so effectively upon initial assessment by the facility nurse. The records reviewed support the statements made by the Executive Director. The medication administration records show that facility staff attempted to obtain the physician's order for the medication in question within 1 day of R1's arrival. The emails reviewed also show that R1's family member had brought medication in after move in that was not sent with R1 upon arrival. While there does appear to be a misunderstanding regarding a medication that R1 should be receiving there is insufficient evidence to show any negligence on behalf of facility staff. Based on the records reviewed and the interview conducted the allegation of "Staff did not ensure medications were dispensed as prescribed" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have occurred, the preponderance of evidence does not prove it.

Allegation 2: Staff did not ensure residents incontinence care needs were being met
LPA Jensen conducted a site tour and observed approximately 30 residents engaged in various activities. All residents observed appeared to be well groomed. LPA Jensen also interviewed 8 residents, 3 staff members, a resident family member and a hospice worker from an outside agency. All residents interviewed stated that their care needs are met in a timely manner. All others interviewed stated residents received frequent and timely incontinence care. One staff member said there have been occasions where residents had been left in soiled briefs but that this occurred only about 2 x a month and the situation was improving. Based on the interviews conducted and LPA Jensen's own observations the allegation of "Staff did not ensure residents incontinence care needs were being met" is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have occurred, the preponderance of evidence does not prove it.

An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20240807163148
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: SKYLINE PLACE SENIOR LIVING
FACILITY NUMBER: 552701305
VISIT DATE: 10/23/2024
NARRATIVE
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LPA Jensen also reviewed an email exchange between the resident care director and a responsible party for a resident. In the email the resident care director advised that the facility's goal is to have staff respond to pages within ten minutes. Based on the call log showing response times to be in excess of the facility's goal or expectations more than 68% of the time the allegation of "Staff do not ensure call signal system requests are answered in a timely manner" is SUBSTANTIATED. A finding of substantiated means that the preponderance of evidence standard has been met.

Deficiencies are being cited on the LIC 9099D. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20240807163148
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: SKYLINE PLACE SENIOR LIVING
FACILITY NUMBER: 552701305
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2024
Section Cited
CCR
87464(f)(4)
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Basic Services
Basic services shall at a minimum include:
Personal assistance and care as needed by the resident... with those activities of daily living ...This requirement was not met as evidenced by:
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The facility has conducted in-service training in August of 2024 with staff and implemented an enhanced call response system which has reduced response time as verified by LPA Jensen. No further plan of correction is required.
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Based on LPA Jensen's review of the call log response times, R1 did not receive personal assistance when needed and waited excessively based on the facility's own standards. This poses a potential risk to the health, safety and personal rights of 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: Lisa Rios
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5