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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608910
Report Date: 09/01/2021
Date Signed: 09/01/2021 03:26:27 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:
09/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Paula Castro - Lead CaregiverTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst(s) Mary Flores and Luis Mora conducted a case management for deficiencies observed during a complaint investigation visit on 9/1/21. LPAs met with Paula Castro and explained the reason of the visit.

The investigation consisted of the following: LPAs conducted a tour of the facility around 10:15am. LPAs observed the following: Kitchen staff was preparing meals and stated to have sharps cabinet and cabinet under the sink with chemicals unlock as she was using items. Living room smog detector had battery sticking out and not functioning. Cabinet in hallway with cleaning supplies was unlock and linen closet had sufficient linens, no blankets observed. LPAs tested water temperature in bathroom #1(B1) and tested at 145.0 degrees F, and bathroom #2 (B2) was tested at 144.5 degrees F. which is not under the required 105 to 120 degrees Fahrenheit. LPAs observed vacant room #1(R1) bed does not have padding, top sheet, blanket, comforter, pillow, and pillow case, LPA observed a blanket in the closet and pillows. Room #2(R2) and #3(R3) with half bed rails, Room #5(R5) no mattress padding, no top sheet, no blanket, no comforter, dresser has a broken drawer, and broken closet door, Room #4(R4), R2, R3,and R1 do not have a night stand. Staff #1 has been working since 7/29/21, who is not associated to the facility administrator will email transfer request and mail verification to LPAs email by 5:00pm, and staff #2 has been working since 8/20/21 and does not have a criminal record background clearance after checking in criminal background system.

Deficiencies were cited under Title 22 Regulations on LIC 809D. Exit interview was conducted with Paula Castro, lead caregiver and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
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 4
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: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2021
Section Cited

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87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal ...shall deliver hot water... maintained to ... a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidence by:
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Based on observation administrator did not ensure water temperature is maintain within the required 105 to 120 degrees F; LPAs tested water temperature in B1 at 145 and B2 at 144.5 degrees F which poses an immediate Health, Safety, and Personal Rights risk to 4 out of 4 persons in care.
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Type A
09/02/2021
Section Cited

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidence by:
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Based on LPAs observation and records administrator did not ensure S2 does not have a criminal background clearance which poses an immediate Health, Safety, and Personal Rights risk to persons in care.

*Civil penalties are being assessed in the amount of $ 500.00.*
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2021
Section Cited

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(a) 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 evidence by:
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Based on LPAs observation administrator did not ensure R3's dresser and closet door are in good repair, and living room smoke detector is working properly which poses a potential Health, Safety, or Personal rights risk to persons in care.
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Type B
09/07/2021
Section Cited

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87307 Personal Accomodations and Services: (a) Living accommodations... shall...(3) Equipment and supplies necessary for personal care...(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads,...
This requirement is not met as evidence by:
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Based on LPA observation administrator did not ensure R1 and R3 did not have all required bedding which poses a potential Health, Safety, or Personal rights risk for 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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2021
Section Cited

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87307 Personal Accomodations(a) Living accommodations and grounds shall be...(3) Equipment and supplies necessary... (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.
This requirement is not met as evidence by:
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Based on observation administrator did not ensure each resident in R4, R2, R1 have a night stand which poses a potential Health, Safety, or Personal rights 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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4