197608910-9-25-2024-31-AS-NMAN-D9WMTN-20241010095349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608910
Report Date: 09/25/2024
Date Signed: 09/25/2024 02:02:47 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2024 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20240130133804

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: 6	DATE:	09/25/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Rowena Bazucang		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Neglect in supervision contributed to resident's death.
Facility staff did not seek medical attention in a timely manner.
Facility staff did not keep accurate records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to complete investigation of the above allegations and to deliver final findings. LPA met with licensee, Rowena Bazucang, and explained the reason for the visit.

--- Neglect in supervision contributed to resident's death.
--- Facility staff did not seek medical attention in a timely manner.

It was alleged that caregivers did not seek medical attention and did not call 911 in timely manner, which contributed to the death of resident #1 (R1). The investigation was initiated by the LPA Abeye Duguma on 01/31/24, at which time LPA inspected the facility and gathered R1’s facility records. The case was referred to CCLD Investigation Branch (IB) and investigation was continued by the Senior Investigator (SI) Sonia Sandoval.
(CONT. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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 31-AS-20240130133804

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SKYHILL QUALITY LIVING	FACILITY NUMBER: 197608910
	VISIT DATE: 09/25/2024

NARRATIVE

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To investigate the allegations, on 03/12/24, Investigator Sandoval requested and reviewed R1’s medical and hospice records and interviewed facility staff members, residents and other witnesses, including police officers from the Burbank Police Department. The review of the hospice records revealed Resident #1 (R1) had a DNR on file. On 01/29/2024 at approximately 7:20a.m., hospice staff attended the facility after being informed of a change in R1’s condition and confirmed R1 had expired. The interviews of facility staff revealed at approximately 6:45a.m., staff reportedly discovered R1 unresponsive (not breathing or with no pulse). Staff #1 (S1) indicated the hospice nurse was immediately notified and several attempts were made to inform the responsible party. The interview of responsible party confirmed that on 01/29/2024 they had several missed calls (commencing at approximately 7:00a.m. hours) from the facility. Responsible party indicated when they called the facility back, they were informed R1 had passed away. The interview of Burbank Police Department Detective revealed the incident was not assigned for further investigation as the decedent was on hospice and there was no evidence of foul play observed by the responding officers.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Facility staff did not keep accurate records.

It was alleged that there was conflicting documentation at the facility regarding the resident. To investigate the allegation, LPA requested pertinent documents at 12:45p.m., and interviewed three (03) staff between 1:00p.m. to 02:40p.m. A review of the facility records clearly shows that the Physician Orders for Life-Sustaining Treatment have different dates on both documents. The Attempt Resuscitation was signed 08/20/2020 and the Do No Resuscitate was signed on 12/22/2022. LPA did not find any documentation in the resident’s file that contradicted these orders. During interviews with staff, all staff stated that resident had an Attempt Resuscitation order and that it was changed to Do No Resuscitate.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.
Exit interview was conducted and a copy of report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

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