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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608910
Report Date: 09/16/2022
Date Signed: 09/16/2022 11:47:26 AM


Document Has Been Signed on 09/16/2022 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
197608910
ADMINISTRATOR:ARUTYUNYAN, TINAFACILITY TYPE:
740
ADDRESS:3919 W VICTORY BLVDTELEPHONE:
(818) 558-5971
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY:6CENSUS: 6DATE:
09/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Arutunyan, TinaTIME COMPLETED:
11:51 AM
NARRATIVE
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Licensing Program Analyst LPA Alberto Lopez conducted an unannounced Case Management visit to follow up on office visit conducted on 04/26/22 regarding Quarterly Case Management visits. LPA met with Carmen Cunanan Caregiver and was met short later by Administrator Tina Arutytunyan and explained the purpose of the visit.

LPA Lopez, cargiver Carmen, and Administrator Tina Arutyunyan toured five resident's rooms, common area and outside physical plant. Facility had enough Nonperishable food for 7 days and perishable food for 2 days. Water temperature was tested in bathroom #1 at 139.7 degrees F and in the shower at 146.7 by room #3 The kitchen sink was tested 145.3 degrees F, and bathroom #2 at 144.9 degrees F., which is not within the required 105-120 degrees F. Record of Resident's Safeguarded Cash Resource was reviewed for R1.

Deficiency cited please see 809D for details. Civil penalties issued for repeat violation within 12 months.

Exit interview conducted and copy of report provided to Administrator

SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2022 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2022
Section Cited

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(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above by Bathroom 1 water temperature tested at 139.7 Degrees F at 10:38am. Shower by room #3 tested 146.7 at 10:55 am, kitchen sink tested at 145.3 at 10:21am Bathroom #2 tested at 144.9 at 10:30am which poses an immediate health, safety or personal rights risk 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.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2