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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 12:35:04 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
08/20/2025 and conducted by Evaluator Ellen Lindstrom
COMPLAINT CONTROL NUMBER: 27-AS-20250820170659
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:
11:00 AM
MET WITH:Valarie Pais, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff did not administer residents' medications as prescribe.
Staff providing care and supervision while impaired.
INVESTIGATION FINDINGS:
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On 9/14/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom and Licensing Program Manager (LPM) Lisa Rios arrived at the facility unannounced to follow-up on this complaint/deliver complaint findings. LPA Lindstrom met with Administrator Valarie Pais (S1) and explained the purpose of the visit.

Allegation: Staff did not administer residents' medication as prescribed
On 9/10/2025, Licensing Program Analyst (LPA) Lindstrom reviewed the facility’s electronic medication administration record (EMAR) for all facility residents for the month of May 2025. The EMAR showed no pattern of missed medication administration in the resident population for both the morning and afternoon passes on any one day in May.

LPA Lindstrom interviewed three family members (F2, F4, and F5) and three staff (S4, S6, and S8), all of whom stated that they had not observed any issues with medication administration.

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-20250820170659
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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Allegation: Staff providing care and supervision while impaired.

On 9/8/2025, LPA Lindstrom interviewed two staff (S4, and S6), who stated that they had never observed care staff impaired on the job. S4 stated that they would not tolerate this. S6 stated that they would have reported it if they had seen this. LPA Lindstrom interviewed one staff (S8), who stated that another care staff (S9) told S8 that they were high on-the-job, and that this was reported to management.

On 9/15/2025, LPA Lindstrom interviewed two residents (R4 and R5), who stated that they had never seen care staff impaired on the job.

Based on interviews and record review, the allegations that staff did not administer residents' medication as prescribed and staff providing care and supervision while impaired are unsubstantiated. Although the allegations may have happened or are 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 California Code of Regulations (CCR), Title 22, Division 6.
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