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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552701305
Report Date: 09/15/2025
Date Signed: 09/15/2025 12:37:17 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
08/25/2025 and conducted by Evaluator Ellen Lindstrom
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: 106DATE:
09/15/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Valarie Pais, AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not report incident to appropriate parties in a timely manner
INVESTIGATION FINDINGS:
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 On 9/15/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to follow-up on this complaint and deliver complaint findings. LPA Lindstrom met with Administrator Valarie Pais (S1) and explained the purpose of the visit.

On 8/27/2025, LPA Lindstrom interviewed S1, who stated that a med tech noticed that a resident was missing from the facility about 10:30 AM on 8/23/2025. LPA Lindstrom received a phone call and voice mail from S1 at 11:41 AM on 8/23/2025 stating that a resident was missing from the facility, and a second call from S1 at 3:20 PM on 8/23/2025 stating that the resident was still missing, that the elopement had been reported to law enforcement, and that Search and Rescue were helping with the search.

On 8/26/2025, S1 submitted an LIC624 Unusual Incident/Injury Report to the Department about R1’s rescue. On 8/29/2025, S1 submitted an additional LIC624 to the Department that documented R1’s elopement and the subsequent facility response in detail.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
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 2
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: 09/15/2025
NARRATIVE
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On the 8/29/2025 LIC624, S1 indicated the following reporting sequence: S2 was notified by facility staff that R1 was missing at approximately 10:50 AM. S2 notified S1 of the elopement at approximately 11 AM. S1 notified R1’s Power of Attorney (POA) at approximately 11 AM. LPA Lindstrom interviewed a family member (F1) of R1, who verified that S1 notified F1 of the elopement around 11 AM on 8/23/2025. The facility immediately initiated its elopement protocols, and staff searched the facility and grounds for R1. S1 called 911 at approximately 11:55 AM to report R1 missing.

Based on interviews with staff and family and records reviewed, the allegation that staff did not report incident to appropriate parties in a timely manner is unsubstantiated. 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, therefore the allegation is unsubstantiated. As a result of this investigation, no deficiencies were cited. The facility was in compliance with the California Code of Regulations (CCR), Title 22, Division 6.

An exit interview was conducted with the Administrator, and a copy of this report was provided.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Ellen Lindstrom
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2