197608910-6-16-2021-28-AS-MVAO-C5BN7U-20210727101320

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608910
Report Date: 06/16/2021
Date Signed: 06/16/2021 08:34:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/14/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210114085352

FACILITY NAME:	SKYHILL QUALITY LIVING		FACILITY NUMBER:	197608910
ADMINISTRATOR:	ARUTYUNYAN, TINA		FACILITY TYPE:	740
ADDRESS:	3919 W VICTORY BLVD		TELEPHONE:	(818) 558-5971
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY:	6	CENSUS: 4	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Tina Arutyunan		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility does not have sufficient staff to meet resident's needs
Resident was not supplied with appropriate bedding
Staff did not notify POA of resident's fall
Facility allowed visitors inside the facility without requiring PPE
Staff restrict resident in bed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Spencer conducted a subsequent visit to deliver the findings for the allegations listed above. LPA Spencer met with administrator Tina Arutyunan and explained the purpose of today's visit.

The investigation consisted of the following: On 1/22/21, LPA Spencer conducted the initial telephonic investigation and interviewed the administrator and staff #1-2 (S1-S2). On subsequent visit on 5/25/21, LPA Spencer took a tour of the physical plant, reviewed medications for 3 residents, and conducted interviews with residents #1-5 (R1-R5), administrator, and S3. R1 is a previous resident and was unable to be reached and R4 is non-verbal. During the course of the investigation, LPA interviewed S4, S5 and 3 family members of R1 (F1-F3), but F1 was unable to be reached. LPA reviewed copies of the staff roster, resident roster, COVID-19 visitor's policy, admissions agreement and for R1: needs and services plan, MAR log, and face sheet.
***See LIC9099C for continuation of this narrative.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/14/2021 and conducted by Evaluator LaJean Nicole Spencer

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210114085352

FACILITY NAME:	SKYHILL QUALITY LIVING		FACILITY NUMBER:	197608910
ADMINISTRATOR:	ARUTYUNYAN, TINA		FACILITY TYPE:	740
ADDRESS:	3919 W VICTORY BLVD		TELEPHONE:	(818) 558-5971
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY:	6	CENSUS: 4	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Tina Arutyunan		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff inappropriately dispense resident's medications
Facility did not provide POA a copy of admission agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Spencer conducted a subsequent visit to deliver the findings for the allegations listed above. LPA Spencer met with administrator Tina Arutyunan and explained the purpose of today's visit.

The investigation consisted of the following: On 1/22/21, LPA Spencer conducted the initial telephonic investigation and interviewed the administrator and staff #1-2 (S1-S2). On subsequent visit on 5/25/21, LPA Spencer took a tour of the physical plant, reviewed medications for 3 residents, and conducted interviews with residents #1-5 (R1-R5), administrator, and S3. R1 is a previous resident and was unable to be reached and R4 is non-verbal. During the course of the investigation, LPA interviewed S4, S5 and 3 family members of R1 (F1-F3), but F1 was unable to be reached. LPA reviewed copies of the staff roster, resident roster, COVID-19 visitor's policy and admissions agreement and for R1: needs and services plan, MAR log, and face sheet.
***See LIC9099C for continuation of this narrative.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 28-AS-20210114085352

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SKYHILL QUALITY LIVING	FACILITY NUMBER: 197608910
	VISIT DATE: 06/16/2021

NARRATIVE

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The investigation revealed the following:

Staff inappropriately dispense resident's medications
It was alleged that medications were not given according to physician's orders and that night time medications were left on the night stand for R1 to take, resulting in missed medications. On 5/25/21, LPA observed that medications were locked and centrally stored. During interviews, the administrator and staff stated that medications are locked and they give medications according to physician's orders. The residents interviewed stated that the staff give them their medicine. However, during the visit on 5/25/21, LPA reviewed medications and MAR logs for 3 residents and observed medication errors. For R5, medications were incorrectly marked off on the MAR but still in the bubble pack. For R2, there was nothing marked on MAR for the month of May even though the medications were taken from the bubble pack. For R4, night time/PM medications were marked as taken on 5/25/21 even though it was daytime when LPA reviewed the medications. The MAR log for R1 was reviewed and it showed days that were not marked off, indicating missed medication.

Facility did not provide POA a copy of admission agreement
It was alleged that R1's responsible party did not receive a copy of the facility's admissions agreement. LPA reviewed a copy of the admissions agreement. During interviews, F3 stated that he asked the administrator for a copy of the admissions agreement on multiple occasions but was never provided with one. The administrator stated that she did not provide R1's responsible party with a copy of the signed admissions agreement because she was unaware that she was required to provide a copy.

Based upon observation, record review, and interviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. CCR Title 22, Division 6, Chapter 8 is being cited on attached LIC9099D.

An exit interview was conducted with the administrator, and copy of this report and appeal rights were provided via email.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 28-AS-20210114085352

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SKYHILL QUALITY LIVING	FACILITY NUMBER: 197608910
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/18/2021 Section Cited CCR 87465(a)(7)	1 2 3 4 5 6 7	87465(a)(7) Incidental Medical and Dental Care: When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by...	1 2 3 4 5 6 7	Administrator stated that she will provide an in-service training for all staff regarding medication administration and provide CCL with training log. In addition, administrator will update all resident's MAR logs and send copy of June MAR logs to CCL by POC due date.
	8 9 10 11 12 13 14	Based on observation and record review, the licensee did not ensure that medications were given according to physician's orders at the prescribed date and time and accurately documented on MAR logs. This poses an immediate health risk for persons in care.	8 9 10 11 12 13 14
Type B 06/23/2021 Section Cited CCR 87507(e)	1 2 3 4 5 6 7	87507(e) Admissions Agreement: The licensee shall provide a copy of the signed and dated current admissions agreement...to the resident or the resident’s representative immediately upon signing the admission agreement. This requirement was not met as evidenced by...	1 2 3 4 5 6 7	Administrator stated that she will provide a copy of admissions agreement to R1's responsible party. In addition, administrator will add verbiage to admissions agreement stating that the signee will receive a copy of admissions agreement and send a copy of updated admissions agreement to CCL by POC due date.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not ensure that R1's responsible party was provided a copy of the signed admissions agreement. This poses a potential personal rights risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 28-AS-20210114085352

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SKYHILL QUALITY LIVING	FACILITY NUMBER: 197608910
	VISIT DATE: 06/16/2021

NARRATIVE

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The investigation revealed the following:
Facility does not have sufficient staff to meet resident's needs
During interviews, the administrator and staff stated that there are 2 staff per shift daily, including overnight. Staff denied that there are any staffing shortages. F2 stated that there were 2 staff when he visited the facility, and F3 stated that R1 told him there were 2 staff during the day and 1 at night. Residents interviewed stated that there are enough staff to assist them. During the visit on 5/25/21, LPA Spencer observed that there were two caregivers and the administrator present. A review of the staff roster shows that there are 2 staff per shift, plus 2 additional on-call staff.
Resident was not supplied with appropriate bedding
During the visit on 5/25/21, LPA Spencer observed that all residents had clean sheets on their bed, and the linen closet had back-up supply of sheets. During interview, the administrator stated that residents have their sheets cleaned daily, and there are back-up sheet sets available for each resident. The administrator stated that when staff clean the sheets, they put a replacement set on the bed right away. S1-S5 stated that sheets are cleaned everyday and a replacement set is put on the bed right away. Residents interviewed stated that they have clean sheets and R5 stated that sheets are cleaned weekly. F3 stated that they had heard that the facility did not keep clean sheets on the bed, while F2 did not remember.
Staff did not notify POA of resident's fall
It was alleged that R1 had a fall in December 2020 and that R1's responsible party was not notified of the fall. A review of R1's face sheet shows that F3 is listed as the responsible party. In an interview, F3 stated that he was not sure if he was notified of a fall, while F2 stated that he had heard about the fall. The administrator stated that the F3 was notified as well as R1's physician. All staff stated that if there is a fall, they notify the administrator who then notifies the family and physician. R5 stated that when she had a fall, her daughter was notified, while other residents stated they were unsure. A review of R1's needs and services plan reveals that the fall occurred on December 19, 2020 and it was documented that the nurse and responsible party was notified.
Facility allowed visitors inside the facility without requiring PPE
During the visit on 5/25/21, LPA Spencer observed signage at the facility regarding mask requirements. A review of the facility's COVID-19 policy shows that visitors are screened, must wear a mask, and use hand-sanitizer upon entry. The administrator stated that visitors are required to wear masks, but stated that F1 visited on several occasions and refused to follow the facility's rules regarding masks. F2 and F3 stated that they were required to wear masks when they visited the facility. All staff interviewed stated that visitors are required to wear masks. R5 did not think visitors were required to wear masks, and R2-R3 was unaware if visitors were required to wear masks. ***See LIC9099C for continuation.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 28-AS-20210114085352

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SKYHILL QUALITY LIVING	FACILITY NUMBER: 197608910
	VISIT DATE: 06/16/2021

NARRATIVE

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Staff restrict resident in bed
During interviews, F2 and F3 stated that they heard that residents are forced to stay in bed all day. The administrator and staff denied that residents are restricted to stay in bed and can be assisted by staff to get exercise daily. The administrator stated that there is 1 bedridden resident, and the rest are non-ambulatory. On 5/25/21, LPA Spencer observed that a resident was walking around with her walker and was assisted by staff when she requested to get out of bed. R2 and R5 stated that they prefer to stay in their room and do not often leave the bed due to preference, while R3 stated that she is always in bed and doesn't like it because it hurts her feet. LPA Spencer observed R3 asking staff to assist her to get out of bed and staff assisted the resident.

Based on observation, interviews and record reviews, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated.

An exit interview was conducted and a copy of the report was provided to administrator via email.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole Spencer	TELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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