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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608910
Report Date: 12/02/2022
Date Signed: 12/02/2022 11:40:42 AM


Document Has Been Signed on 12/02/2022 11:40 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
GREATER LA AC/SC, 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: 5DATE:
12/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Tina Arutyunyan TIME COMPLETED:
11:46 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 Rowena P. Bacugang Caregiver and was met short later by Administrator Tina Arutytunyan and explained the purpose of the visit.

LPA Lopez, with caregiver Rowena present, tested the water temperature and it measured between 105.5 to 106.8 which is within range. LPA and administrator 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. Record of Resident's Safeguarded Cash Resource was reviewed for R1. All 3 exit door alarms were not functioning properly during visit.

Deficiency cited, please see 809D for details.

Exit interview conducted and copy of report provided to Administrator Tina Arutytunyan

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/02/2022 11:40 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
GREATER LA AC/SC, 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: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2022
Section Cited

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87705(j) Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement was not met as evident of:
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Facility retains dementia resident and alarms on exit doors were not working properly.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2