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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552701305
Report Date: 02/26/2025
Date Signed: 02/26/2025 05:17:21 PM

Unsubstantiated


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
02/24/2025 and conducted by Evaluator Renee Campbell
COMPLAINT CONTROL NUMBER: 27-AS-20250224103421

FACILITY NAME:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
552701305
ADMINISTRATOR:PAIS, VALERIEFACILITY TYPE:
740
ADDRESS:12877 SYLVA LANETELEPHONE:
(209) 288-4630
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:135CENSUS: 104DATE:
02/26/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff does not ensure facility is kept free of odors
Staff does not ensure residents rooms are kept in clean, sanitary conditions
Staff do not ensure residents are spoken to in an appropriate manner
INVESTIGATION FINDINGS:
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On 02/26/2025, Licensing Program Analyst (LPA) Renee Campbell arrived at the facility unannounced to conduct an investigation on a complaint that was submitted to the Department on 02/24/25. LPA Campbell met with Valerie Pais, Administrator and explained the purpose of the visit.

During the investigation, LPA Campbell observed rooms, hallways and stairwells, reviewed client and staff rosters and interviewed a random selection of residents.

Regarding the allegation that staff does not ensure the facility is kept free of odors, LPA Campbell observed odors in two of the six rooms selected for observation. The rooms were observed to be clean without obstructions but food was observed to have been left out in R2's room for a pet cat and R3 had been recently changed. Because residents prefer to keep their doors closed, LPA Campbell observed no odors in the facility hallways or common areas.

Report continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
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-20250224103421
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: 02/26/2025
NARRATIVE
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Regarding the allegation that staff does not ensure residents rooms are kept in clean, sanitary conditions, of the six rooms LPA Campbell observed no pests or obstructions were observed on the floor. Furniture was in good repair and the kitchens and bathrooms were clean and clear of any debris. Of three residents interviewed (R7, R5, R8), all reported weekly visits by staff to clean their rooms and collect their laundry and a willingness by staff to remove additional trash at their request.

Regarding the allegation that staff speak to residents in an inappropriate manner, of the three residents interviewed (R7, R5, R8) none reported being spoken to inappropriately or hearing other residents being spoken to inappropriately or shouted at.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies cited. Exit interview was held and a copy of report was given to Valerie Pais, Administrator.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5