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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 12:36:04 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-20250820090538
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:
09/15/2025
UNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Valarie Pais, AdministratorTIME COMPLETED:
11:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff leave residents in soiled diapers/linens for extended period of time.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 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.

The LPA interviewed three family members (F2, F4, and F5), who reported that they had had no issues with incontinence care at the facility.

On 9/8/2025, LPA interviewed two staff (S6 and S8), who reported having observed residents receiving inadequate incontinence care. S6 stated that they had seen some residents in soaked briefs every day or every other day. S8 stated that they had observed bedbound residents left in soiled briefs and some residents with skin breakdown.
(Continued on 9099-D)
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-20250820090538
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 9/15/2025, LPA Lindstrom interviewed two residents (S4 and S5). S4 stated that they had experienced no issues with incontinence care. S5 stated that staff did a good job with incontinence care and that their room remained odor-free. The LPA Lindstrom observed S5's room and it was odor-free.

Based on interviews and record review, the above allegation 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 California Code of Regulations (CCR), Title 22, Division 6. An exit interview was conducted and copy of this report was provided to the Administrator.
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