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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 552701305
Report Date: 02/09/2026
Date Signed: 02/09/2026 10:32:22 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
12/12/2025 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20251212161459
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: 107DATE:
02/09/2026
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Executive Director Valerie PaisTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Lack of supervision resulted in a resident harming another resident

Unauthorized charge to resident's account
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to this facility to deliver complaint findings. LPA Lund met with Executive Director Valerie Pais and explained the purpose of the visit. Census 107

Allegation: Lack of supervision resulted in a resident harming another resident.
It was alleged that due to lack of supervision it resulted in a resident harming another resident. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted, it was determined that on 12/11/2025, R1 and R2 were in an elevator traveling to dinner. R2 was using an assistive device while exiting the elevator, at which time R1 became impatient and pulled R2’s hair and struck R2 with a cane.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
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 4
Control Number 27-AS-20251212161459
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: 02/09/2026
NARRATIVE
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A review of R1’s pre-admission appraisal indicates that R1 has a tendency to become easily frustrated and may lash out physically. Additionally, R1’s care plan documents occasional behavioral issues, including aggressive behavior, socially inappropriate conduct, and verbally or physically inappropriate actions. The care plan further specifies that facility staff are required to demonstrate special tolerance and/or receive appropriate training. It also states that R1 is to be monitored for safety and redirected to a calmer, quieter environment at the early signs of behavioral escalation.

Based on this information, due to lack of supervision it resulted in a resident harming another resident.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes

Allegation: Unauthorized charge to resident's account-It was alleged that there were unauthorized charges to the resident’s account. During the course of this investigation, LPA conducted interviews and reviewed facility records. Based on interviews conducted, it was learned that the facility admitted that their records show that the facility added an addition charge for care to the resident’s ledger without notifying the resident. In addition, a review of the facilities files show that the facility administrator asked for the resident’s account to be credited the amount that was initially taken off accidentally. Based on the information gathered, there is sufficient evidence to prove that there were unauthorized charges to the resident’s account.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

An exit interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Citations on this Visit Report are Under Appeal!

Control Number 27-AS-20251212161459
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: 02/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
02/10/2026
Section Cited
HSC
1569.312(e)
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(e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
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Licensee shall provide a statement of correction to the LPA by POC date. Facility shall have an update care plan that specifies how they will assist and mitigate R1’s behavior from harming other residents in care.
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This is not met as evidenced by: Based on interview and record review, the licensee did not ensure that the facility had proper supervision to monitored R1 from physically assaulting R2. This poses an immediate health, safety, and personal rights risks to persons in care.
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Under Appeal
Type B
02/23/2026
Section Cited
CCR
87507(g)(3)(B)2
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2. A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admission agreement.This is not met as evidenced by:
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Licensee shall provide statement of acknowledgement and correction to LPA by POC date.
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Based on interview and record review, the licensee did not ensure that the resident’s responsible party was notified of the additional charges on the resident’s care plan. This poses a potential health, safety, and personal rights risks to persons in care.
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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: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
12/12/2025 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20251212161459

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: 107DATE:
02/09/2026
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Executive Director Valerie PaisTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not notify resident's responsible party of an incident in a timely manner.
INVESTIGATION FINDINGS:
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Allegaton: It was alleged that staff did not notify resident’s responsible party of an incident in a timely manner- Based on interviews conducted, it was revealed that the facility did notify the resident’s responsible party of an incident within a timely manner. An interview with the resident’s responsible party corroborates this statement.

This agency has investigated the complaint allegation(s). This agency has found that the complaint was UNFOUNDED, meaning that the allegation(s) were false, could not have happened and/or was without a reasonable basis. This agency has therefore dismissed the complaint.
An exit interview was conducted and a copy of this report and appeals rights was provided to the facility at the end of this visit
Unfounded
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4