Skyline Place Senior Living

Allegation investigated: Lack of supervision resulted in a resident harming another resident Unauthorized charge to resident's account

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. Substantiatedthe state’s words, verbatim · CDSS document, Feb 9, 2026 · control 27-AS-20251212161459

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not provide adequate resident care.

On 10/1/2025, Licensing Program Analyst (LPA) Triel Ellen Lindstrom arrived at the facility unannounced to deliver complaint findings. LPA Lindstrom met with Administrator Valarie Pais, explained the purpose of the visit, and conducted an interview. Allegation: Staff does not provide adequate resident care. On 6/5/2025, LPA Arielle Pascua conducted the 10-day site visit and interviewed two staff. S1 stated that a resident’s family had recently been concerned about them, but S1 had explained to the family that the resident’s health was declining and that they were developing new behavioral expressions. S1 stated that no other issues had been brought to their attention. S2 stated that there were no complaints with any families regarding care at this time. On 9/8/2025 and 9/10/2025, LPA Lindstrom interviewed three family members and three staff members. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 1, 2025 · control 27-AS-20250530110109

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff leave residents in soiled diapers/linens for extended period of time.

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) Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 15, 2025 · control 27-AS-20250820090538

Allegation investigated: Staff did not administer residents' medications as prescribe. Staff providing care and supervision while impaired.

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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 15, 2025 · control 27-AS-20250820170659

Allegation investigated: Staff did not report incident to appropriate parties in a timely manner

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 responthe state’s words, verbatim · CDSS document, Sep 15, 2025 · control 27-AS-20250825115709

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Lack of supervision, resulting in resident eloping from facility

On 8/27/2025, Licensing Program Analysts (LPAs) Vincent Moleski and Triel Ellen Lindstrom arrived unannounced to open this complaint investigation. LPAs Moleski and Lindstrom met with Administrator Valarie Pais and explained the purpose of the visit. The LPAs interviewed Pais and reviewed two LIC 624s submitted by the facility about a resident elopement that occurred on Saturday 8/23/2025. Pais stated that on the morning of 8/23/2025, a med tech went to the resident’s room about 8:30 AM to pass medications. The resident’s spouse stated that she was sleeping. When the med tech returned about 9:30 AM to pass medications, the resident’s spouse stated that the resident was out walking their dog. When the med tech returned about 10:30 AM to pass medications, the resident’s spouse stated that the resident had not returned to their room. The med tech called the Administrator to report the resident’s absence and the facility began their elopement protocol. [continued on 9099-C] Substantiatedthe state’s words, verbatim · CDSS document, Aug 27, 2025 · control 27-AS-20250825115709

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff did not provide timely medical care

On 02/26/25, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to present findings regarding a Complaint. LPA Campbell met with Valerie Pais and explained the purpose of the visit. Regarding the allegation that staff did not provide timely medical care, on 09/10/24, a complaint was filed with the Department alleging neglect/lack of care and supervision. During the course of the investigation, the Department conducted interviews with staff and reviewed files for S4 and R1. When interviewed, staff reported that S4 did not check on R1 and other residents when requested due to COVID-19. Based on these findings, it was SUBSTANTIATED that staff did not provide timely medical care. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may alsthe state’s words, verbatim · CDSS document, Feb 26, 2025 · control 27-AS-20241002164831

Allegation investigated: Staff does not ensure facility is kept free of odors Staff does not ensure residents rooms are kept in clean, sanitary conditions Staff do not ensure residents are spoken to in an appropriate manner

On 02/26/2025, Licensing Program Analyst (LPA) Renee Campbell arrived at the facility unannounced to conduct an investigation on a complaint that was submitted to the Department on 02/24/25. LPA Campbell met with Valerie Pais, Administrator and explained the purpose of the visit. During the investigation, LPA Campbell observed rooms, hallways and stairwells, reviewed client and staff rosters and interviewed a random selection of residents. Regarding the allegation that staff does not ensure the facility is kept free of odors, LPA Campbell observed odors in two of the six rooms selected for observation. The rooms were observed to be clean without obstructions but food was observed to have been left out in R2's room for a pet cat and R3 had been recently changed. Because residents prefer to keep their doors closed, LPA Campbell observed no odors in the facility hallways or common areas. Report continued on 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 26, 2025 · control 27-AS-20250224103421

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff served unsafe food

On 12/2/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director Valerie Pais and explained the purpose of today's visit. LPA Jensen interviewed the Executive Director who advised that residents began presenting with gastrointestinal (GI) symptoms on 11/26/24 in the PM. By 11/29/24 there were 26 residents and 13 staff members with GI symptoms. As of this date there are 33 residents with GI symptoms and 25 staff. Residents are returning from the hospital with discharges paperwork that states they have an unspecified gastrointestinal virus. In the presence of LPA the Executive Director contacted the Administrative Director of Acute Services with Adventist hospital who confirmed that stool samples were taken from some residents and a panel of testing was conducted to rule out food bourne illness. Tests to date have come back negative for food bourne illness. Cothe state’s words, verbatim · CDSS document, Dec 2, 2024 · control 27-AS-20241127112128

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not ensure call signal system requests are answered in a timely manner

On 10/23/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue an investigation in to a complaint investigation related to the above listed allegations. LPA Jensen met with Executive Director Valerie Pais and explained the purpose of today's visit. During the course of the investigation LPA Jensen reviewed care response logs and emails between the responsible party for resident 1 (R1) and facility staff. During the course of an interview with the Executive Director, LPA Jensen asked what a reasonable amount of time would be for staff to respond to a resident that activates their call pendant. The Executive Director responded that response times can vary depending on what else is happening in the facility such as a resident emergency for example but generally a call should be responded to within 15-20 minutes. LPA Jensen reviewed response logs for R1 for the week of 7/21/24 to 7/27/24. During that period of time R1 activated the call pendant 16 timesthe state’s words, verbatim · CDSS document, Oct 23, 2024 · control 27-AS-20240807163148

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not ensure that resident's hygiene needs are being met. Facility is charging resident for services not provided.

On 4/29/24 Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegation. LPA Jensen met with Executive Director Aimee Jo Mattson and explained the purpose of today's visit. During the course of the investigation the Department conducted interviews with a Home Health Nurse, the facility Regional Nurse, the Executive Director and resident 1 (R1). The Department also reviewed documentation that includes an Admission Agreement, Needs and Service Plans, Home Health documentation, facility policy, in-service training records, and resident chart notes. Based on the facility bathing policy, "staff will ensure resident's participation to bathe or shower on a routine basis...Twice weekly and as needed will be scheduled." Based on LPA Jensen's review of the skin observation sheet R1 was bathed 6 times in ten weeks. Substantiatedthe state’s words, verbatim · CDSS document, Apr 29, 2024 · control 27-AS-20240208161140

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.