197608910-9-13-2021-28-AS-MGFS-C6TSR6-20210913140550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608910
Report Date: 09/13/2021
Date Signed: 09/13/2021 02:05:58 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 LIVING		FACILITY NUMBER:	197608910
ADMINISTRATOR:	ARUTYUNYAN, TINA		FACILITY TYPE:	740
ADDRESS:	3919 W VICTORY BLVD		TELEPHONE:	(818) 558-5971
CITY:	BURBANK	STATE: CA	ZIP CODE:	91505
CAPACITY:	6	CENSUS: 4	DATE:	09/13/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	12:28 PM
MET WITH:	Tina Arutyunyan - Administrator		TIME COMPLETED:	02:20 PM

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	Licensing Program Analyst(s) LPA Mary Flores conducted a plan of correction (POC) visit at the facility for deficiencies given on 9/1/21. LPA Flores met with Tina Arutyunyan administrator and explained the reason for the visit. On 9/1/21 LPA Flores conducted a complaint investigation visit and conducted a physical plant review. During the visit LPA cited type A deficiencies due on 9/2/21 and type B deficiencies. Today's visit LPA Flores conducted a POC visit to cleared the deficiencies due on 9/2/21 and 9/7/21. The following type A deficiencies were cited on 9/1/21: 87303(e)(2) - Maintenance and Operation - Facility's water temperature was tested at 145 degrees F in bathroom #1 and 144.5 degrees F in bathroom #2. LPA Flores measured water temperature in bathroom #1 and tested at 118.8 degrees F and bathroom #2 tested at 117.5 degrees F. 87355(e)(1) - Criminal Record Clearance - Staff #2 was observed working since 8/20/21 and does not have a criminal background clearance. LPA Flores observed staff leave the facility during the visit of 9/1/21 and did not observed staff working at the facility. 87303(a) - Maintenance and Operation - Resident #3's dresser and closet door are not in good repair, and living room smoke detector is not working. LPA Flores observed dresser in room #5 removed from room, receipt for purchased dresser was email to LPA during the visit, closet door was repaired and smoke detector was tested and working properly. (CONTINUED LIC 809C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

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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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
	VISIT DATE: 09/13/2021

NARRATIVE

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87307(a)(3)(C) - Personal Accommodations and Services - Resident #1 and #3 did not have all required bedding items. LPA Flores observed the following items in Resident #1 and #3 beds; have bottom sheet, flat sheet, blanket, room #4, #1, and #3 have a comforter, pillow, and pillow case. Closet with linens have additional blankets and comforters.

87307(a)(3)(B) - Personal Accommodations and Services - administrator did not ensure each resident in Room #4, #2, #1 have a night stand. LPA Flores observed a night stand in room #1,#2,#4.

Exit interview was conducted with Tina Arutyunyan administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC809 (FAS) - (06/04)

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