197608910-11-4-2021-28-AS-LHIS-C9BPRN-20211202103301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608910
Report Date: 11/04/2021
Date Signed: 11/04/2021 04:29:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/01/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211101125943

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: 3	DATE:	11/04/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Staff, Maria Limaco		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Resident sustained injuries from a fall while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced complaint investigation for the allegation listed above. LPA met with Staff, Maria Limaco, and explained the purpose of the visit. The licensee, Tina Arutyunyan, arrived shortly thereafter.

The investigation consisted of the following:
LPA Chan obtained copies of the resident roster, staff roster, and documents pertaining to Resident #1 (R1). LPA toured the facility with the licensee and conducted interviews with the licensee, Administrator, 3 Staff, 2 Residents, R1, R1's family member, and Staff at Cedar Assisted Living facility. R1 is no longer residing at the facility.

(Continue on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20211101125943

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/04/2021

NARRATIVE

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The investigation revealed the following:
In regards to allegation, resident sustained injuries from a fall while in care. It is alleged that Resident #1 (R1) fell and sustained bruises underneath the eyes and swelling around the nose. LPA interviewed the Staff #1 (S1), who was on duty for the overnight shift but did not witness the fall. S1 stated that the fall occurred around 2 a.m. When S1 heard R1's fall, S1 immediately went into the room to observe R1 by the end of the bed and already standing up. S1 checked on resident for any injuries and asked what had happened. R1 responded by saying that R1 might had slipped on the wet floor but there was no pain. R1 agreed to take a Tylenol as a precaution and went to sleep right after but S1 did not observe any bruising or swelling in the face at that moment or in the morning. Per R1's family member, R1 stated that R1 either fainted or lost balance while trying to get up. R1 also refused to go to the doctor when family member went to visit that morning and noticed some redness by the nose. The licensee showed LPA a photo of R1's alleged injury from the fall but also stated it is difficult to determine if the fall caused any bruising or swelling since R1 normally has puffiness underneath the eyes. LPA interviewed the Marketing Director of Cedar Assisted Living who stated that the R1's sister informed her that R1 had a fall at the former facility. R1 was not observed with any swelling or bruises in the eye or nose area upon admission at new facility.
According to interviews conducted with facility personnel, Resident #1 (R1) does not require much assistance and is able to ambulate on own. All the staff reported that R1 moves around the house using a walker sometimes but does not need staff to assist with mobility, which is also mentioned on the Appraisal/Needs and Services Plan and/or Physician's Report. However, Staff check on all residents regularly and respond right away when they hear residents' calls. LPA also interviewed 2 out of 3 residents which both stated Staff check on them and assist with their needs.
Although R1 had fallen, there is no supporting evidence indicating a lack of supervision or neglect from the staff. In addition, there is no evidence to show that the fall caused any form of bruising or swelling in the eyes and nose area.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with the licensee via telephone. A copy of this report along with the appeal rights were provided to the Staff whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021

LIC9099 (FAS) - (06/04)

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