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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 03:37:59 PM

Document Has Been Signed on 05/26/2022 03:37 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:
02:30 PM
MET WITH:Administrator Tina Arutyunyan TIME COMPLETED:
04:01 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA)s Alberto Lopez and Mary Flores conducted an unannounced Case Management visit to follow up on office visit conducted on 04/26/22 regarding Quarterly Case Management visits. LPAs met with Carmen Cunanan Caregiver and was met short later by Administrator Tina Arutytunyan and explained the purpose of the visit.

LPAs Lopez, Flores and Administrator Tina Arutyunyan toured three resident's rooms, common area and outside physical plant. Facility had enough Non perishable food for 7 days and perishable food for 2 days. Water temperature was tested in bathroom #1 at 122.6 degrees F and in the shower at 122.1 by room #3 The kitchen sink was tested 123.7 degrees F., and bathroom #2 at 123.3 degrees F., which is not within the required 105-120 degrees F. LPAs and Administrator observed one knife in the kitchen drawer that was unlocked and cleaning solutions where unlocked and accessible to residents. LPAs reviewed residents files and observed facility has 3 bedridden residents out of 5 residents. Resident #1(R1), #2(R2), #3(R3) have ambulatory status noted as bedridden in physician's report. Administrator stated R1 is bedridden and will discuss status of R2 and R3 with primary physician. Record of Resident's Safeguarded Cash Resource was reviewed for R1.


Deficiencies cited on 809D per Title 22 Regulations.

Exit interview was conducted with Administrator Tina Arutyunyan and copy of report provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
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 3
Document Has Been Signed on 05/26/2022 03:37 PM - It Cannot Be Edited


Created By: Alberto Lopez On 05/26/2022 at 02:37 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 A
05/27/2022
Section Cited
CCR
87303(2)

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2. Hot water temperature is to be maintained between 105-120*F.(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 degree C) and not more than 120 degree F (49 degree C)
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Licensee will adjust water temperture and provide evidence to LPA and certify that water temperture has been adjusted and within range of 105 degrees F and 120 degress F by 5/27/22.
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LPA's and admiistrator observed that the hot water measured from a low of 122.1 to degrees F. to a high of 123.7 degrees F. in the kitchen and restrooms.
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Type A
05/26/2022
Section Cited
CCR87309(a)(1)

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(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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Licensee locked up the cleaning solutions and knife during visit. Deficiency is cleared as of 5/26/22.
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LPAs, Administrator and DSP observed cleaning soutions and knifes unlocked and accesible to residents.
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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:Alberto Lopez
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)
Page: 2 of 3
Document Has Been Signed on 05/26/2022 03:37 PM - It Cannot Be Edited


Created By: Alberto Lopez On 05/26/2022 at 03:03 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 A
05/27/2022
Section Cited
CCR
87204(a)

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87204 Limitations - Capacity and Ambulatory Status: (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time...

This requirement is not met by evidence as:
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Licensee will contact primary physicain for R2 and R3 and verify ambulatory status for the R2 and R3 and will submit physician's report to the department by 5/27/22.
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Licensee did not ensure R2 and R3 ambulatory status was within the limitations of the license which allows 1 bedridden resident which poses an immediate health, safety, or personal righs risk to 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:Alberto Lopez
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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