<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608910
Report Date: 01/03/2024
Date Signed: 01/03/2024 03:22:28 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/19/2022 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 28-AS-20221219161213
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:
01/03/2024
UNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Rowene BacucangTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility unaware of resident's condition.
Facility did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/03/24 at 1:26 p.m. Licensing Program Analyst (LPA) Evelin Rios conducted a subsequent complaint visit to this facility to conclude the investigation regarding the above allegations. LPA was greeted by staff, Rowene Bacucang who called the administrator Tina Arutyunyan to inform them LPA was at the facility. LPA informed the administrator the purpose of the visit. Administrator was unable to meet LPA at the facility and designated staff to sign todays report.
During the course of the investigation, on 12/28/22, at 9:52 a.m. LPA interviewed three (3) out of six (6) residents in care. LPA conducted interviews with staff and the administrator from 10:12 a.m. to 11:12 a.m. LPA conducted a record review from 11:12 a.m. to 12:45 p.m. and obtained copies of pertinent information. On 12/30/22 from 9:30 a.m. to 10:12 a.m. LPA conducted follow-up interviews with two (2) out of two (2) staff in regards to the allegations above. From 10:12 a.m. to 11:15 a.m. LPA obtained more copies of pertinent information. From 10:51 a.m. to 11:01 a.m. LPA conducted a follow-up interview with the administrator.
(Cont. on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
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 2
Control Number 28-AS-20221219161213
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SKYHILL QUALITY LIVING
FACILITY NUMBER: 197608910
VISIT DATE: 01/03/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation #1: Facility unaware of resident's condition. In regards to the allegation, it was reported resident #1 (R1) had a medical emergency and staff could not provide paramedics with any of R1's medical information when requested. LPA's interview with staff #3 (S3) present during the events in question revealed they had called the administrator Tina to inform her of R1's change in condition at around 11:00 a.m. because she was fine during breakfast at around 8:30 a.m. According S3, Tina then called R1's Hospice nurse from Miracle Healing Hospice Inc. S3 goes on to state, Hospice nurse arrived at the facility around 3:00 p.m. and takes R1's vitals. At this time R1 has a fever of 104 degrees Fahrenheit and is not eating. The Hospice nurse instructs staff to give R1 Tylenol to reduce the fever and give oxygen. Hospice nurse tells staff to continue to observe R1's condition. According to S3 they call Tina and requests permission to call 911. S3 calls 911 at around 8:00 p.m. because R1's conditioned had not improved. According to S3 they were trying to give all the information requested by the paramedics but the paramedic was not allowing staff to explain. S3 goes on to say they believe their own accent could have been an issue. On 12/28/2023 LPA asked staff two (2) out of the three (3) staff to provide residents' primary diagnoses. LPA confirmed diagnoses with residents physician's report. LPA questioned staff where they would find residents' records and Hospice records. Staff were able to show LPA where resident files are stored. Based on the information obtained, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED at this time.

Allegation #2: Facility did not seek medical attention in a timely manner. In regards to the allegation, it was reported staff did not seek adequate medical attention or timely intervention for resident #1 (R1) which resulted in deterioration of R1. According to a reliable witness, R1 arrived to the emergency room and was not responding to stimuli. As reported by S3 they contacted the administrator first who then according to S3 and confirmed by the administrator they contacted the Hospice nurse. LPA reviewed R1's Hospice records which revealed R1 had been admitted to Hospice. LPA attempted to contact Hospice agency and Hospice nurse but was unsuccessful and did not receive a returned. Upon discharge R1 would be readmitted to the facility. On 01/03/24 LPA confirmed R1 is still at the facility, a resident re-appraisal and needs and services was conducted. LPA attempted to interview R1 on 01/03/24 at 2:50 p.m. According to Rowene, R1 has been improving and is eating regularly. According to interviews facility contacted Hospice first as directed to do so before calling 911. Based on the information obtained, although allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED at this time.
Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2