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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 552701305
Report Date: 06/18/2025
Date Signed: 06/19/2025 09:27:42 AM

Document Has Been Signed on 06/19/2025 09:27 AM - 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:SKYLINE PLACE SENIOR LIVINGFACILITY NUMBER:
552701305
ADMINISTRATOR/
DIRECTOR:		PAIS, VALERIEFACILITY TYPE:
740
ADDRESS:12877 SYLVA LANETELEPHONE:
(209) 288-4630
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY: 135CENSUS: DATE:
06/18/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Valarie Pais, Designated Facility AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 06/18/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived for an unannounced for a Case Management meeting. The LPA met with Valarie Pais, the Designated Facility Administrator (DFA), and explained the purpose of the visit. The purpose of the visit was to discuss the notification that the Department had received that there was a nanny cam set up and recording in a resident room.

The DFA stated that a staff caregiver notified her of the video camera in R1's room on 06/03/2025. The DFA, who was off-site at the time, called the Director of Health and Wellness (DHW) Kayla Varney and directed her to call the resident's family to inform them that the video camera in the resident's room was against regulation. The DHW called the family early evening to let them know this and that staff was going to remove the camera immediately. The DFA stated that Resident Care Director Rachel Cole removed it from the resident's room by 6 PM.

The DFA stated that on 06/07/2025, one of R1's granddaughters contacted her to inform her of possibly suspicious activity in their grandfather's room that was captured on the camera. She forwarded two videos to the DFA. The first video was time stamped 06/03/2025 at 2:41 PM and showed staff looking in the resident's kitchen cabinets and counters. The DFA clarified with Kristin that this was kitchen staff looking for dirty dishes, as R1 received food service in his room. The second video was time stamped 06/03/2025 at 5:36 PM and showed staff taking an Ensure from the resident's kitchen. The DFA conducted an investigation and determined that this was a caregiver that took the Ensure without authorization. The investigation resulted in the employee's termination.


NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SKYLINE PLACE SENIOR LIVING
FACILITY NUMBER: 552701305
VISIT DATE: 06/18/2025
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The DFA stated that the resident's family requested permission to reinstall the video camera in the resident's bedroom so that they can see their grandfather more often. The DFA inquired what was involved in getting permission for this. Senior Executive Director Alyssa Sellers of Milestone Retirement joined the conversation by cell phone. The LPA informed them that the facility must submit an exception waiver request for a video camera to the Department and that its Plan of Operations and Admission Agreement would need to be updated accordingly if approved. The LPA stated that approval of an exception waiver for a video camera was granted by the Department's Program Manager.

The LPA and the DFA toured the R1's apartment. The LPA observed that the camera was no longer in the apartment. The LPA toured the Med Tech room and observed the video camera in storage there.

Based on observations made during the inspection of the facility and an interview with the Administrator, the
Department has found the facility to be noncompliant and has cited it for one deficiency. An exit interview was
conducted, and Appeal Rights were discussed with the DFA. Copies of this LIC 809/LIC 809D report and appeal rights were provided to the DFA.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Ellen Lindstrom
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2025 06:03 PM - It Cannot Be Edited


Created By: Ellen Lindstrom On 06/18/2025 at 05:25 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SKYLINE PLACE SENIOR LIVING
FACILITY NUMBER: 552701305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2025
Section Cited
CCR
87211

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency…:(1) A written report…within seven days of the occurrence…(D) Any incident which threatens the welfare, safety or health of any resident.
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The Designated Facility Administrator shall submit a LIC 624 documenting the incident to the Department. This report can be sent to the LPA Triel Ellen Lindstrom at ellen. lindstrom@dss.ca.gov.
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This requirement was not met as evidenced by:
Based on interview and record review, the Licensee did not ensure that a LIC624 was submitted to the Department notifying it of the termination of an employee for theft from a resident.
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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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Ellen Lindstrom
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2025


LIC809 (FAS) - (06/04)
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