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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608910
Report Date: 03/30/2022
Date Signed: 04/01/2022 11:21:22 AM


Document Has Been Signed on 04/01/2022 11:21 AM - It Cannot Be Edited

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: 5DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:53 AM
MET WITH:Tina ArutyunyanTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced visit for the purpose of an annual required. LPA met with S1 and S2, an explained the purpose of today's visit. At 10:15 Administrator Arutyunyan arrived and assisted with the remainder of the visit. Upon arrival LPA checked association and observed S2 not on the association list. S2 confirmed that she has worked here for a week.

Facility is licensed to serve 6 over the age of 60. 6 of which is non-ambulatory, and 1 can be bedridden. Hospice waiver approved for 4 residents. Facility is a one-story house in a residential area. LPA made a complete tour of facility which included: 6 bedrooms, 2 bathrooms, living room, kitchen, dining room, laundry area, outdoor area, and garage. Administrator certificate #6002858740 expires 4/5/2023.

The following was observed, reviewed, and inspected: Bedrooms #1-5 are designated for residents. Bedroom #6 is designated for staff. Each bedroom contained the required furniture and linens as mandated. Bathroom was observed to contain working fixtures, and were equipped with necessary grab bars. Resident bathroom was missing non-slip mat. Water temperature measured in the residents bathroom at 123.6 degrees F, which is not in the required range of 105-120 degrees F. Kitchen was inspected and no deficiencies observed; cleaning materials and knives were secured in a locked cabinet, appliances were clean and operational, and an adequate supply of 2 days perishable and 7 days non-perishable. LPA observed sufficient linen,required documents were posted in the office area, trash cans with tight fitting lids. Smoke detector and carbon monoxide detectors were tested and operable, fire extinguisher(s) fully charged, front and back yard clean and free of debris. Staff files for administrator, S1 and S2 was reviewed. Administrator stated S2 do not have a file yet because she is newly hired. Medication for all residents was reviewed. The last disaster drill was conducted on March 4th 2022 .

Report continued on 809C
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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Document Has Been Signed on 04/01/2022 11:21 AM - It Cannot Be Edited

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: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 above by Bathroom 1 water temperature tested at 123 Degrees F. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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Administrator shall mainitain a water temperature of 105-120 degrees F. for bathroom #1. Administrator will submit picture proof to LPA by POC date.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(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: (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, LPA observed upon arrival that S2 was not associated, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2022
Plan of Correction
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Administrator agrees to complete transfer request through guardian before S2 can be allowed to work. Administrator understands S2 can not be present in the facility unitl they are associated. Transfer request is completed for S2. Proof of correction due to CCLD by POC date.

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: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/01/2022 11:21 AM - It Cannot Be Edited

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: 03/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 above in Bathroom #1 was missing skid matts, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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Administrator will ensure there are skid matts are located in everybathroom. Proof of correction/ purchase is due back to LPA by email on POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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
VISIT DATE: 03/30/2022
NARRATIVE
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Pursuant to Title 22 Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Civil penalties issued/ Exit Interview Conducted / Appeal Rights provided / A Copy of the Report Issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4