Inspection Reports for Sky Park Gardens

The visit was an unannounced case management inspection conducted to conclude the investigation of Resident 1's death that occurred on 2024-01-04.

The investigation found no violations of Title 22 regulations, no deficiencies were observed or cited during the inspection, and staff interactions and medication administration were appropriate.

The inspection was an unannounced complaint investigation visit conducted in response to an allegation that facility staff made sexual advances to a resident in care.

The investigation included interviews and record reviews, revealing inconsistencies in the allegations and no corroborating evidence. The accused staff member's schedule did not align with the alleged incidents, and the resident denied any sexual assault claims. The allegation was found to be unsubstantiated.

The complaint alleged that facility staff made sexual advances to a resident. The investigation found no evidence to substantiate the claim, and the allegation was determined to be unsubstantiated.

An unannounced complaint investigation visit was conducted on 02/27/2025 regarding multiple allegations including failure to provide transportation, meal service issues, pest control, response to resident calls, and illegal eviction.

The investigation substantiated the allegation that the facility was in disrepair with maintenance issues such as leaking faucets and ceiling leaks. All other allegations including failure to provide transportation, meal service, pest control, timely response to calls, and illegal eviction were unsubstantiated based on interviews, record reviews, and observations.

The complaint investigation was triggered by multiple allegations received on 12/23/2024, including failure to provide transportation to medical appointments, failure to meet dietary needs, pest control issues, untimely response to resident calls, and illegal eviction. The allegation of facility disrepair was substantiated, while all other allegations were unsubstantiated.

The visit was an unannounced follow-up complaint investigation regarding an allegation that staff were not preventing a resident from harassing other residents in care.

The investigation found no consistent evidence that the resident intentionally harassed others or that staff failed to intervene appropriately. Staff actively supervised the resident and addressed behaviors related to cognitive impairments. The allegation was determined to be unsubstantiated.

The complaint alleged that staff were not preventing a resident from harassing other residents. The investigation included interviews and record reviews, concluding the allegation was unsubstantiated.

The visit was conducted as a follow-up complaint investigation regarding an allegation that the facility installed a surveillance device in a resident's room without consent.

The investigation found no evidence of surveillance devices in resident rooms. Surveillance cameras were only installed in common areas. The allegation was determined to be unfounded as the devices in question were standard safety equipment such as smoke detectors and sprinkler systems.

The complaint alleged that a surveillance device was installed in a resident's room without consent. After interviews, observations, and record reviews, the allegation was found to be unfounded.

The visit was an unannounced case management inspection regarding a death incident reported for a resident who passed away on 2024-10-15.

The investigation focused on reviewing the death certificate, which listed cardiac arrest as the immediate cause of death with contributing health conditions. No autopsy or biopsy was performed, and no signs indicated the death was questionable. No deficiencies were cited during this visit.

The inspection was an unannounced required annual inspection visit conducted to ensure compliance with Title 22 regulations for the facility.

The inspection found multiple deficiencies including five out of six fire extinguishers being expired, one resident bathroom sink faucet lacking hot water, absence of a grab bar by the toilet in one resident bathroom, and failure to conduct quarterly emergency drills since COVID. Technical advisories were also provided for minor repairs and cleaning.

The visit was an unannounced case management follow-up on a death report of a resident received on 2024-03-08. The investigation focused on circumstances surrounding the resident's death on 2024-03-05.

No deficiencies were cited during this visit per California Code of Regulations, Title 22. The Licensing Program Analyst conducted file review and obtained pertinent documents but could not interview staff who first discovered the resident. The investigation will continue with a future visit.

The visit was triggered by a death report complaint received on 2024-03-08 regarding a resident found on the floor having difficulty breathing and subsequently pronounced dead after paramedics performed CPR.

An unannounced case management inspection was conducted to ensure the health and safety of residents and to address additional questions regarding the death of a resident (R1).

Based on interviews, information gathered, and documentation reviewed, no deficiencies were assessed at the time of inspection.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations of rodent infestation and unclean conditions at the facility.

The investigation found substantiated evidence of a rodent infestation and unclean conditions, including rat feces in multiple resident rooms and dirty carpets, posing a potential health and safety risk to residents.

The complaint investigation was substantiated based on observations of rodent infestation and unclean conditions. The preponderance of evidence standard was met.

The inspection was an unannounced Required - 1 Year annual inspection visit conducted to assess compliance with regulatory standards.

The facility was observed to be clean and in good repair with required furniture, lighting, and adequate food supplies. Staff and resident files were reviewed, and all staff had appropriate background clearances and training. No deficiencies were cited during the inspection.

The inspection visit was conducted as an unannounced complaint investigation following a complaint received on 2023-08-02 alleging that staff failed to treat residents with dignity and respect.

The investigation substantiated the complaint that facility staff failed to treat residents with dignity and respect. Interviews with residents revealed that 6 out of 10 residents reported staff entering rooms without knocking, turning on lights without turning them off, and not shutting doors, posing potential health and safety risks.

The complaint was substantiated based on interviews with 10 residents and 10 staff. Six residents expressed concerns about staff behavior related to dignity and respect. Staff denied the allegations. The preponderance of evidence supported the complaint.

The visit was conducted as a case management follow-up in response to learned deficiencies from a prior complaint investigation regarding water temperature being too hot in a resident's room.

The inspection found that the resident bathroom sink water temperature measured at 128.5°F, exceeding the regulatory limit of 120°F, posing a potential health and safety risk to residents.

The visit was in response to a complaint investigation (control number: 27-AS-20230802083802) where Resident #1 reported water being too hot in their room, confirmed by measurements exceeding regulatory temperature limits.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations of staff neglect, failure to meet residents' needs, and withholding food from residents at Skypark Manor.

The investigation included interviews with residents and staff, review of facility files and medical documents, and observations. All allegations were found to be unsubstantiated or unfounded, with no evidence supporting neglect, failure to meet residents' needs, or withholding food. No deficiencies were cited.

The complaint investigation was triggered by allegations that staff neglected residents, failed to meet residents' needs, and withheld food from residents. Interviews with 10 residents and 10 staff members consistently denied these allegations. The findings were unsubstantiated or unfounded, meaning there was no evidence or reasonable basis to support the complaints.

The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was assaulted by another resident while in care.

The investigation substantiated the allegation that a resident was assaulted by another resident. The facility staff attempted to intervene and separate residents to prevent altercations, but an assault occurred on 11/18/2022. No injuries or fractures were sustained by the assaulted resident.

The complaint was substantiated. The allegation was that a resident was assaulted by another resident while in care. The investigation included review of resident medical records, facility incident reports, and interviews. The preponderance of evidence standard was met.

An unannounced Plan of Correction (POC) visit was conducted to verify correction of citations issued during the case management visit on 10/31/2022.

The facility corrected the previously cited deficiencies under Title 22 Regulations and complied with the terms of the POC by the due date. However, a new citation will be issued for failure to request an exception for a resident with a prohibited health condition.

The visit was an unannounced case management incident inspection conducted in response to an incident report dated 10/27/2022 regarding a resident falling from a scooter on the upper level.

No deficiencies were observed during the visit. The resident involved in the incident was sent to the emergency room and underwent multiple CT scans which were all negative. Medication adjustments were made due to allergies.

The visit was an unannounced case management health check focused on Resident 1 regarding a pressure injury.

No deficiencies were observed during the visit. Resident 1 has a stage 2 sacral pressure ulcer with granulation tissue and no signs of infection. Follow-up with home health care and Nurse Practitioner is planned to ensure healing progression.

Unannounced Required 1 Year Annual Inspection Visit to assess compliance with Title 22 regulations and facility licensing requirements.

The facility was inspected for physical plant conditions, infection control, staff certifications, and resident care documentation. Deficiencies were found related to expired medication, incomplete medication signing, outdated assessments for residents with dementia, and failure to provide timely treatment for a resident's pressure injury, posing immediate risk to resident health and safety.

The visit was an unannounced case management incident investigation regarding a resident-to-resident altercation that occurred on 09/19/2022, where one resident hit another with a can of soda causing injury.

No deficiencies were observed during the visit. The injured resident refused medical assistance and was found to have no current injury. The facility reported no further incidents between the residents involved and stated residents are monitored closely.

The visit was triggered by a complaint incident report dated 09/19/2022 involving a resident altercation resulting in injury. The complaint was investigated and found to have no deficiencies.

The visit was an unannounced case management visit conducted due to a recent change of ownership at the facility.

The facility was observed to be clean and in compliance with Title 22 regulations. No deficiencies were observed during the visit. Staff and residents showed no signs or symptoms of COVID-19 in the last 10 days.

The Licensing Program Analyst conducted an unannounced case management visit due to the recent change of ownership.

The facility was observed to be clean and in compliance with Title 22 regulations, with no deficiencies noted. Staff and residents showed no signs of COVID-19 symptoms, and all reviewed files were complete with updated documentation.

The visit was an announced pre-licensing inspection conducted to evaluate the facility's readiness for licensing and to ensure compliance with health and safety regulations.

The facility was found to have no deficiencies. The physical plant, emergency supplies, fire safety equipment, and resident rooms were inspected and found to be in compliance with regulatory standards. The pre-licensing was completed and passed.

The visit was conducted as part of the original licensing process for the facility, including a telephone call with the applicant/administrator to confirm understanding of licensing requirements and program policies.

The applicant and administrator successfully completed Component II of the licensing process, demonstrating understanding of facility operation, staff qualifications, program policies, and other regulatory requirements. The COVID-19 Mitigation Plan was also discussed and emailed.