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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608910
Report Date: 05/26/2022
Date Signed: 05/26/2022 03:11:53 PM

Document Has Been Signed on 05/26/2022 03:11 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: 5DATE:
05/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tina Arutyunyan - Administrator TIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores and Alberto Lopez conducted a case management visit - plan of correction(POC) to follow up on deficiency given during a complaint investigation on 4/26/22. LPAs met with Carmen Cunanan Caregiver and explained the reason for the visit. Administrator Tina Arutyunyan arrived 15 minutes later.

On 4/26/22 LPA Flores delivered findings for complaint 28-AS-20210824084953 during an office meeting at the Monterey Park Regional Office. Section 87217 (b) Safeguard for Resident Cash, Personal Property, and Values was noted on LIC 9099D. Deficiencies POC due date was 5/10/22. The deficiency was not cleared by the due date.

On 5/26/22 LPA Flores noted correction for P&I funds to be return to R3 in the amount of $996 as R3 moved out of the facility on 10/27/22. During this visit LPA is providing the deficiency on LIC 809D.

Exit interview was conducted with Tina Arutyunyan Administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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 2
Document Has Been Signed on 05/26/2022 03:11 PM - It Cannot Be Edited


Created By: Mary G Flores On 05/26/2022 at 01:10 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: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2022
Section Cited
CCR
87217(b)

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87217 Safeguards for Resident Cash, Personal Property, and Values: (b)... facility shall take appropriate measures to safeguard residents' cash resources,...which have been entrusted to the licensee.... The licensee shall give the residents receipts for all such articles or cash resources.
This requirement is not met as evidence by:
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The licensee will refund P&I funds for R1 amount $2329, R2 amount $1104, and R3 amount $996 and proof must be submitted to the deparment by 5/27/22.
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Based on documents reviewed licensee did not ensure to maintain record receipts for items purchase with P&I funds for R1,R2,R4 which poses a potential health, safety, personal rights risk to the 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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
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