Skye Luis Care Home

Type of visit: Case Management - Annual Continuation

Unannounced Annual Inspection visit was made by Licensing Program Analyst (LPA) Kimberly Viarella to this facility on 08/28/26. LPA identified herself upon arrival, stated the purpose of the visit, and asked to speak with Licensee/Administrator. LPA met with Annie Rodriguez and the two toured the facility. The inspection began in the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. The fire extinguisher was last serviced on 03/03/26 by Cintas and was also in compliance. LPA inspected the resident 5 bedrooms and 1 staff bedroom. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time. LPA noted soap, paper towels, trash cans with lids and grab bars in the bathrooms and non-skid surfaces in the shower unit. The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. LPA observed that all screens and gutters were in good repair. During the last annual inspection, the LPA noted that the right side rear fence was in disrepair, many sections have been replaced or repaired. LPA observed another area in need of repair and LPA a technical violation (TV) was provided. The LPA observed medications were stored in a large locked metal cabinet in office area and inaccessible to residents in care. A review of the First Aid kit by the LPA found it to be complete and in compliance. During this visit, LPA observed 2 caregivers as well as the Licensee /Administrator attending to residents. LPA reviewed the activities that Rodriguez purchased since last year, and provided additional suggestions for residents to try. LPA compared Guardian Roster to the LIC 500 to ensure that all staff were appropriately background cleared as required. All were in compliance a the time of this inspection. A file review was completed by the LPA. The review of 2 resident' files and 2 staff files were completed. All were in compliance at the time of this inspection. LPA observed that the mandated reporter form needed to be updated as the one staff had been filling out was last revised in 2015. The Administrator printed out new copies for all staff to review and sign. According to the California Code of Regulations, Title 22, no deficiencies were observed or cited during today's inspection. A copy of this report was provided and an exit interview was conducted with the Administrator.the state’s words, verbatim · CDSS document, Aug 28, 2026

Type of visit: Required - 1 Year

On 5/13/2025, Licensing Program Analyst Arvin Villanueva (LPA) arrived unannounced at this facility to conduct their annual inspection visit. LPA met with Administrator Annie Lyn Rodriguez (AD) and stated the purpose of the visit. LPA was accompanied by Jenny Olson, CDSS Trainer, Arlene Krause and Katie Savin, Professors at California State University for training purposes. Present during this visit were 5 residents in care with 3 staff on duty including the AD. During this visit, LPA observed one resident in the living room sitting on a reclining chair throughout this visit. The other 4 residents were in their bedroom. 2 of the residents did had family visited. 2 outside agency staff were also present attending residents. Per interview with AD, there are no activity supplies to be reviewed at this time. LPA evaluated the physical plant with AD to ensure the health and safety of the residents in care. The facility is a one-story home located in a residential neighborhood. Areas inspected are including but not limited to the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the inside of the facility to be clean and in good repair at this time. LPA inspected 4 of 6 resident bedrooms and were to be equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the hot water temperature in 2 resident bathroom between 107 and 113 degrees Fahrenheit. Room temperature was observed at 71 degrees Fahrenheit. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Two fire extinguisher were observed and were last inspected on 3/5/2025. Smoke and carbon monoxide detectors were observed. LPA observed centrally stored medications, toxins, and sharp objects were kept locked and inaccessible to residents in care. No bodies of water was observed at this time. Fireplace was observed to be screened and non-operational at this time. {1 of 2} Outdoor area was inspected. Facility has 2 side gate exits. One of the gate is in need of repair as evidenced by the door is dragging at the bottom. The fence at the right side is also in need of repair. Debris on the right side of the house needs cleaning. Review of 4 resident files (R1, R2, R3 R4) include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. Each resident reviewed had PRN authorization letter on file. Medication review of 2 residents include review of physician orders for over-the-counter medications. No issues were noted at this time. Review of 3 staff files (S1, S2, and S3) include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Administrator Certificate is current. No issues were noted at this time. Facility conducts quarterly disaster drill. Facility has a dementia and infection control plan. Administrator to submit current Liability Insurance Certificate, LIC500 and LIC308 to the Department. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were observed during today's visit. Exit interview was conducted and a copy of the report was provided upon exit. {2 of 2}the state’s words, verbatim · CDSS document, May 13, 2025

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Legal/Non-compliance

On 2/11/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a quarterly case management visit due to a current stipulation order in place. The facility is licensed under a probationary license. LPA met with 2 staff on duty and stated the purpose of this visit. The Administrator, Annie Lyn Rodriguez (AD) is currently out of the country. The designated staff, Marvin Rodriguez and Monalisa Salipan, arrived shortly after. Present in today's visit were 5 residents in care with 2 staff on duty. Facility is approved for 6 non-ambulatory elderly residents, fire cleared for 1 bedridden resident, and approved for 1 hospice resident. LPA conducted a physical inspection of the facility. LPA observed residents were in their bedroom watching TV and being assisted by staff. Another staff was observed to be preparing residents' lunch during this visit. Room temperature was measured at 75*F and hot water temperature was measured at 116*F in 1 of 3 resident bathrooms. 3 of 5 bedrooms were observed to be clean and good repair. 2 of 3 bathrooms were observed to be maintained and good repair. Medications, sharp objects and toxic chemicals were observed to be locked and inaccessible to residents in care. Stipulation was observed in a conspicuous place at the office desk area. During this visit, LPA conducted review of 2 of 6 resident records and 2 staff records. Resident records reviewed have updated Physician's Report and Needs and Services Plan. Current residents are not receiving hospice services. 2 of 2 staff record reviewed have current 1st Aid/CPR certificates and fingerprint clearance. Per stipulation, facility conducts monthly staff training. Last training was conducted on 1/5/25. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with the Administrator.the state’s words, verbatim · CDSS document, Feb 11, 2025

Type of visit: Case Management - Legal/Non-compliance

On 10/7/24, at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct their quarterly case management visit due to a current stipulation order in place. The facility is licensed under a probationary license.. LPA met with the Administrator, Annie Lyn Rodriguez (AD) and stated the purpose of the visit. Present in today's visit were 5 residents in care with 2 staff on duty. Facility is approved for 6 non-ambulatory elderly residents, fire cleared for 1 bedridden resident, and approved for 1 hospice resident. LPA conducted a physical inspection of the facility. LPA observed residents were in their bedroom watching TV and being assisted by staff. Another staff was observed to be preparing residents' lunch during this visit. Room temperature was measured at 72*F and hot water temperature was measured at 120*F in 1 of 3 resident bathrooms. AD adjusted the water heater and later LPA re-measured hot water temperature and was at 113*F. 3 of 5 bedrooms were observed to be clean and good repair. 2 of 3 bathrooms were observed to be maintained and good repair. Medications, sharp objects and toxic chemicals were observed to be locked and inaccessible to residents in care. Stipulation was observed in a conspicuous place at the office desk area. During this visit, LPA conducted review of 3 of 5 resident records and 3 staff records. Resident records reviewed have updated Physician's Report and Needs and Services Plan. Based on review of Incident Reports and Physician's Reports, Technical Assistant (TA) was provided to AD to create a fall prevention plan for 1 of 5 residents in care and submit plan to LPA. 3 of 3 staff record reviewed have current 1st Aid/CPR Certificates and ongoing training. Per stipulation, facility conducts monthly staff training. Last training was conducted on 9/27/24. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with the Administrator. NOTE: This report was amended on 2/11/25. LPA corrected the room temperature.the state’s words, verbatim · CDSS document, Oct 7, 2024

Type of visit: Case Management - Legal/Non-compliance

On 7/24/24, at 10:09am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct their quarterly case management visit due to a current stipulation order in place. The facility is licensed under a probationary license.. LPA met with the facility administrator, Annie Lyn Rodriguez and stated the purpose of the visit. Present in today's visit were 3 residents in care with 2 staff on duty. At 11am, LPA conducted a physical inspection of the facility. Facility is approved for 6 non-ambulatory elderly residents, fire cleared for 1 bedridden resident, and approved for 1 hospice resident. LPA observed residents were in their bedroom watching TV and being assisted by staff. Room temperature was measured at 72*F and hot water temperature was measured at 114*F in 1 of 3 resident bathrooms. Bedrooms were observed to be clean and good repair. Bathrooms were observed to be maintained and good repair. Medications, sharp objects and toxic chemicals were observed to be locked and inaccessible to residents in care. Fence at the right side of the facility was observed to be leaning. Discussion with administrator Annie Lyn Rodriguez to have a plan in place to repair the fence as soon as possible. At this time, the condition of the fence is not posing health and safety risks to residents and staff. LPA conducted review of 3 staff and 4 resident records. 3 of 3 staff reviewed have current 1st Aid/CPR certificate. 1 of 4 resident files reviewed need to update their Physician Report (dated 6/6/23). Discussion with Annie Lyn to obtain current medical assessment for 1 of 4 residents as required. LPA reviewed 2 of 4 resident medications and are in compliance at this time. {page 1 of 2} Per review of the stipulation order: Current Respondents operate in strict compliance with the regulations and statues governing RCFE? Facility was observed to be in compliance during this visit. Is there full compliance with the regulations and statues governing RCFE? Facility was observed to be in compliance during this visit. Stay of exclusion is valid only for the conduct identified in the second amended accusation and second amended statement of issues. Facility was observed to be in compliance during this visit. Stay of exclusion is valid for respondent Annie Lyn Rodriguez association to facility 1 & 2. Facility was observed to be in compliance during this visit. Respondent completed 18 hrs. of training after 90 days of this Stipulation? Annie Lyn has completed 18 of 18 hours of training. Stipulation is posted in a conspicuous place. Stipulation order was observed to be posted at the office area near the entrance. Has there been incidents to report recently? Recent incidents has occurred and report to be submitted and still within reporting requirements. Advisory was provided to Annie Lyn to ensure verbal reporting of incidents need to be done within the next day of the incident either via phone or email. Respondent cannot retain residents who have prohibited conditions. Annie Lyn has not retained nor accepted residents with prohibited conditions at this time. Within 30 days of this stipulation, respondent have a written plan for obtaining timely medical care for residents? Have training of all staff on procedures? Per review of previous visits, Annie Lyn has submitted a written plan. Within 30 days of this stipulation, respondent have plan in place to for extended absences of the administrator on record? Have training for staff on procedures? Per review of previous visits, Annie Lyn has submitted a written plan. Monthly training of staff provided? Per document review, monthly training was being conducted. Last monthly training was conducted on 6/20/24. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with the Administrator. {page 2 of 2}the state’s words, verbatim · CDSS document, Jul 24, 2024

Type of visit: Required - 1 Year

On 5/22/24, at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct the required annual inspection visit. LPA met with the facility administrator, Annie Lyn Rodriguez, and explained the purpose of the visit. Present during today's visit were 5 residents in care with 2 staff on duty. Facility is approved for 6 non-ambulatory resident and fired cleared for 1 bedridden resident. Additionally, facility is approved for 1 hospice resident. At 10:30am, LPA inspected the facility’s physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathroom, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. The facility is a one-story structure located in a residential neighborhood. There were no bodies of water on the premises at this time. Outside of the facility was observed to be clean and clear of obstructions. LPA observed outdoor furniture for clients’ use. During the inspection outside, LPA observed the fences at the side and the back of the yard are in need of repair. Technical assistance was provided. LPA observed 5 resident bedrooms and 3 resident bathrooms. There is one staff room in the facility. LPA observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the client’s personal belongings. Bed linens, comforters, and bath towels were adequately stocked during the visit. Bathroom is observed to be sanitary, operational and adequately supplied, including with grab bars and non-skid flooring. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were locked and not accessible to residents in care. Facility maintain adequate supply of clean linens for resident use. Food supplies were observed to be stored appropriately. Sufficient 2-day perishable and 7-day non-perishable food was maintained adequately. Room temperature was maintained in the facility at 75 degrees F. Water temperature in the bathroom was measured at 111 degrees F. One fire extinguisher was last serviced on 3/12/24. Smoke detectors/ carbon monoxide were observed. {Con't toLIC809-C} {Con't from LIC809} Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed for accuracy for two residents. First aid kit was observed to have adequate supplies and accessible to staff. The facility maintains for each client Centrally Stored Medication, Destruction Record and PRN Log. All mandated inspection control posters were posted. LPA observed personal rights poster. Facility has internet access available for residents in care. LPA observed sufficient equipment and supplies to meet activity program needs of residents in care. During this visit, residents were in their bedrooms. During this inspection, LPA conducted an audit of facility files, 5 resident files, and 3 staff files for regulatory compliance. All 3 staff files reviewed contained required contents including health screening, TB results, and current first aid/CPR. Resident files contained updated Physician Reports and Needs and Services Plans. Medication review was conducted for 2 randomly selected residents for compliance. No medication issues were observed at this time. Per review, facility conducts quarterly fire drills. Last fire drill was conducted in March 2024. Facility’s liability insurance is current per regulatory requirements. LPA reviewed facility’s disaster plan and infection control plan. LPA was provided updated copy of LIC 308, LIC 500, 1 and liability insurance. No deficiencies were observed during this visit. An exit interview was conducted with Administrator Annie Lyn Rodriguez, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 22, 2024

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Health Checks

On 4/24/24, at 10:45am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct their quarterly case management visit. LPA met with the facility administrator, Annie Lyn Rodriguez and explained the purpose of the visit. During today's visit, 4 residents in care were present with 2 staff on duty. Facility is approved for 6 non-ambulatory elderly residents, fire cleared for 1 bedridden resident, and approved for 1 hospice resident. LPA observed the current stipulation order place in a conspicuous place in the front area of the home at the office desk. LPA toured the physical plant of the facility. During this visit, all residents were in their bedrooms. 4 of 5 resident bedrooms were observed to be cleaned and free of obstruction. One resident bedroom was not observed due to resident sleeping during the tour. The room temperature was observed to be at 71 degrees F. All 3 bathrooms were observed to be clean and free of clutter. Hot water temperature in the hallway bathroom was measured at 114 degree F. During the tour of the kitchen, LPA observed 2 resident medications were stored in the kitchen refrigerator, which are unlocked and accessible to resident in care. LPA observed the administrator, Annie Lyn Rodriguez, immediately placed the medications in a small refrigerator and placed it in a locked room marked "staff room" in the kitchen area. Other medications are located at the office area and were observed to be properly stored, locked and inaccessible to resident in care. A technical advisory was also provided to the administrator to obtain and place a thermometer inside the freezer and refrigerator to ensure regulatory temperature is maintained at all times. Con't to LIC809 The outdoor area was observed be free of clutter and obstructions. There is a freezer outside the covered patio at the back area of the facility. LPA observed the side gate, located at the right side of the facility, to not work properly as the bottom is stuck on the ground and LPA used a bit of force to open the gate. Technical advisory was provided to the administrator to repair the issue. The back storage was observed to be unlocked. Inside the storage, LPA did not observed sharp or dangerous objects. However, technical advisory was still provided to the administrator to lock the storage as a precaution. Through resident file review, it was discovered that 2 of 5 residents' LIC 602A was signed by nurse practitioners, in place of physicians. Technical advisory was provided to the administrator to submit a waiver request for non-physicians to sign residents' medical assessments and prescriptions. LPA reviewed 3 staff files. All 3 staff have current 1st aid/CPR certificates. Monthly training as per stipulation is conducted on a monthly basis. Last training was conducted on 3/4/2024. All deficiencies are cited from the California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8 ; and the Health and Safety Code 1569.38 Residential Care Facilities on the LIC 809-D. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. Exit interview conducted with Annie Lyn Rodriguez and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Apr 25, 2024

87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the regulation cited above. LPA observed 2 resident medications were stored in the kitchen refrigerator and are accessible to residents in care which poses an immediate health, safety and personal risks to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2024

Plan of correction: Corrected during this visit. Adminstrator placed the 2 medications inside a small refridgerator and placed it inside a locked room. Administrator to submit a statement of understanding of the regulation, CCR Section 87465 to the Department by the POC due date of 4/25/2024. Administrator to conduct a staff training on the subject of properly storing medications and submit a proof of completed training to the Department by 5/1/2024.

Type of visit: Case Management - Health Checks

On 1/10/2024, at 10:30am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a quarterly case management visit. LPA Villanueva met with Administrator on record Annie Rodriguez and explained the purpose of the visit. During this visit, LPA observed 2 resident in care with 2 staff on duty. LPA observed the current stipulation order place in a conspicuous place in the front area of the home at the office desk. LPA and Administrator Annie toured the facility to ensure compliance with Title 22 regulations. LPA observed 1 resident in care who was watching TV and 1 resident was napping. Two bedrooms are currently being occupied. The facility has an approved hospice waiver for 1, and there is currently no resident on hospice or bedridden. Common areas and resident bedrooms were observed to be clean, organized, and free from obstructions. Facility was observed to have emergency water and a fully stocked pantry. Room temperature was observed at 76 degrees F. Hot water temperature was measured at 112 degree F. Staff working in the home were observed to be fingerprint cleared. LPA observed staff trainings from June 2023 to December 2023 with topics that align with the stipulation order. LPA also reviewed 4 staff files and 2 resident files. Technical advisory was provided to the administrator to obtain PRN authorization letter from the residents' physician. The licensee/administrator has completed 18 out of 18 hours of training related to observation change in residents, duty to obtain timely medical care, prohibited health conditions and prevention of pressure injuries. LPA also reviewed current LIC308. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with Annie Lyn Rodriguez, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 10, 2024