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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608910
Report Date: 08/17/2021
Date Signed: 08/17/2021 02:18:41 PM

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: 4DATE:
08/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tiny ArutyunanTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA was greeted by administrator Tina Arutyunan and discussed the purpose of today's visit. This single-story home contains six (6) bedrooms, three (3) bathrooms, a living room, kitchen, dining area, backyard, and attached garage.
The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, hand sanitizer and sign-in sheet. A temperature check log was present but not updated.
  • COVID-19 signage was placed in several areas including entrance, hallway, and bathrooms.
  • Facility maintained a 30-day supply of PPE.
  • One (1) out of three (3) bathrooms were in disrepair including the toilet, sink, and shower.
  • There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods.
  • Cleaning solutions and sharps were locked and inaccessible.
  • Water temperature was measured in kitchen/bathrooms and were within required 105-120 degrees F.
  • Each room contained required furniture including bed, dresser, night stand, lamp and chair.
  • Medications were locked and centrally stored. Medications were reviewed for four (4) residents and facility did not maintain a 30-day supply of medications.
  • Staff wore face masks throughout their shift.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • At least one (1) fire extinguisher was observed to be fully charged and serviced.
  • Client files were inspected and emergency contact information was up to date.
  • Administrator qualifications were checked and administrator certificate expires on 4/2023.
  • Obstructions were observed in the outdoor area as two bed springs and headboards were placed there and were not properly discarded.
Pursuant to Title 22, deficiencies were cited on the attached 809D. An exit interview was conducted and a copy of this report and appeal rights were provided to the administrator.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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 5
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: 08/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 3 bathrooms. The toilet did not flush, the sink was draining slowly, and the shower was leaking water. This poses a potential health and safety risk to persons in care.
POC Due Date: 08/17/2021
Plan of Correction
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The administrator requested a plumber to fix the toilet, shower, and sink. The deficiency was cleared prior to the end of the visit.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited due to two mattress springs and head boards obstructing the outdoor passageway and not being discarded. This poses a potential safety risk to persons in care.
POC Due Date: 08/17/2021
Plan of Correction
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The administrator removed the items to the dumpster area for trash removal. The deficiency was cleared prior to the end of the visit.
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 YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: LaJean Nicole SpencerTELEPHONE: (323)981-3342
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2021
LIC809 (FAS) - (06/04)
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