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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552701305
Report Date: 08/27/2025
Date Signed: 08/27/2025 03:26:29 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
08/25/2025 and conducted by Evaluator Ellen Lindstrom
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250825115709
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: DATE:
08/27/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Valarie Pais, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Lack of supervision, resulting in resident eloping from facility
INVESTIGATION FINDINGS:
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On 8/27/2025, Licensing Program Analysts (LPAs) Vincent Moleski and Triel Ellen Lindstrom arrived unannounced to open this complaint investigation. LPAs Moleski and Lindstrom met with Administrator Valarie Pais and explained the purpose of the visit.

The LPAs interviewed Pais and reviewed two LIC 624s submitted by the facility about a resident elopement that occurred on Saturday 8/23/2025. Pais stated that on the morning of 8/23/2025, a med tech went to the resident’s room about 8:30 AM to pass medications. The resident’s spouse stated that she was sleeping. When the med tech returned about 9:30 AM to pass medications, the resident’s spouse stated that the resident was out walking their dog. When the med tech returned about 10:30 AM to pass medications, the resident’s spouse stated that the resident had not returned to their room. The med tech called the Administrator to report the resident’s absence and the facility began their elopement protocol. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
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
Control Number 27-AS-20250825115709
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: 08/27/2025
NARRATIVE
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The Administrator called the resident's child, their attorney in fact, about 11 AM to inquire whether the resident was at their home. The Administrator called the Tuolumne County Sheriff’s Office a little before noon to report the elopement. Staff began a search of the facility for the resident, including resident rooms, facility grounds, and perimeter of the facility. The Administrator and facility staff joined the SARs teams with the search of the surrounding area, including the neighborhood adjacent to the facility up the hill, as the resident’s friend and child currently live there. The Administrator reviewed video footage from a nearby business and church. The resident was found by a SAR team on Sunday evening 8/24/2025 located in bushes down a ravine. The Administrator rode with the resident in the ambulance to the hospital. The Administrator stated that the resident had no injuries, but was dehydrated. The resident was released from the local hospital on Monday 8/25/2025 about 3:30 AM and returned to the facility. The resident and their spouse moved into a new unit in Memory Care that same day.

The LPAs reviewed the resident’s service plan dated 11/22/2024. The LPAs observed that the plan included the goal that the resident had a “History of wandering outside the community…Health and safety may be jeopardized.” The resident was reappraised after the 8/23/2025 elopement to ensure that their current service plan addressed the resident’s recent wandering. The resident’s new plan dated 8/26/2025 includes the same goal with the same language as the 11/22/2024 plan in regard to wandering.

The LPAs reviewed the resident’s LIC 602A Physician’s Report for Residential Care Facilities for the Elderly (RCFE), signed by a physician on 1/6/2025. The report stated on page 4 that the resident was “Able to leave the facility unassisted.” This report does not reflect the information contained in the service plan written a month and a half before. The 1/6/2025 LIC 602A was based on the resident’s last exam, which was in late September 2024, prior to the completion of the resident’s service plan in November 2024. The resident was diagnosed with dementia and epilepsy, according to the LIC 602. No documentation was available to suggest that the resident’s physician was notified of the wandering behavior identified in their November 2024 service plan. This deficiency will be addressed in a separate report. The LPAs noted that the resident’s file did not contain an elopement risk assessment prior to the resident’s recent elopement on 8/23/2025.

Health and Safety Code Section 1569.312(d) states that facility staff must remain “aware of the resident's general whereabouts, although the resident may travel independently in the community.” Additionally, 22 CCR Section 87705(e)(5) states that “Facility staff shall ensure the continued safety of residents [with a dementia diagnosis] if they wander away from the facility…”
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20250825115709
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: 08/27/2025
NARRATIVE
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This facility is hereby cited per 22 CCR Section 87705(e)(5). Due to a violation involving a lack of supervision of a resident, a civil penalty in the amount of $500 is hereby assessed. The licensee was informed that a civil penalty assessment based on Health and Safety Code Section 1569.49(f) is currently under review and may be assessed at a later date. Once this has been determined, CCLD personnel will return to assess the civil penalty, if necessary.

An exit interview was held. Appeal rights and a copy of this report were left with Pais.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20250825115709
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: 08/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2025
Section Cited
CCR
87705(e)(5)
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“Facility staff shall ensure the continued safety of residents if they wander away from the facility without violating Sections 87468.1, Personal Rights of Residents in All Facilities and Section 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities.” This requirement was not met as evidenced by:
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Licensee agrees to provide staff trainings on the topics of elopement and notification procedures. Licensee agrees to provide LPA Lindstrom a plan regarding these scheduled trainings by POC due date.
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Based on interview and record review, facility staff were aware of previous wandering behaviors which jeopardized the health and safety of the resident, yet did not ensure the resident’s safety during an episode of wandering behavior, which poses an immediate health, safety, and/or personal rights risk.
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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: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5