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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608910
Report Date: 05/25/2021
Date Signed: 05/25/2021 04:03:11 PM

Document Has Been Signed on 05/25/2021 04:03 PM - 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: 4DATE:
05/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Tiny ArutyunanTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Spencer initiated a case management visit due to deficiencies found during a complaint investigation (Control#:28-AS-20210114085352). The case management visit was completed during the course of the complaint investigation and LPA Spencer met with Tina Arutyunan and explained the purpose of the visit.

During the complaint investigation, LPA took a tour of the physical plant including the kitchen, dining room, resident rooms, medications area, and bathrooms. At 12:17 p.m., LPA observed a block of sharp knives and scissors left on the counter top in the kitchen. LPA also observed a drawer of knives, cleaning solutions, and laundry detergents that were stored in an unlocked cabinet. At 1:05 p.m., LPA Spencer brought it to the staff's attention and they placed the knives and scissors in the cabinet and locked it up. They also locked the cabinet containing the cleaning solutions and laundry detergent.

Per Title 22 Regulations, Division 6 Chapter 8, deficiencies were cited on the attached 809D.

An exit interview was conducted with administrator and a copy of the report and Appeal Rights was provided via email.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2021
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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Document Has Been Signed on 05/25/2021 04:03 PM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 05/25/2021 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/25/2021
Section Cited
CCR
87705(f)

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87705(f) Care of Persons with Dementia:
The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by:
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The administrator removed the knives and scissors from the countertop an placed it in a locked cabinet. Administrator locked cabinet containing cleaning supplies, knives, and laundry detergent. Deficiency was cleared prior to the end of the visit.
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Based on observation, the licensee did not ensure that knives, scissors, cleaning solutions, and laundry detergent was stored inaccessible for 4 out of 4 residents. This poses an immediate safety 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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2021


LIC809 (FAS) - (06/04)
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