<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609098
Report Date: 09/01/2021
Date Signed: 09/01/2021 02:27:55 PM

Document Has Been Signed on 09/01/2021 02:27 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 LIVING #2FACILITY NUMBER:
197609098
ADMINISTRATOR:ARUTYUNYAN, TINAFACILITY TYPE:
740
ADDRESS:626 N LAMER STTELEPHONE:
(818) 558-5971
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 6CENSUS: 6DATE:
09/01/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Elmer Manalong, StaffTIME COMPLETED:
02:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Galarza initiated a Case Management- Deficiencies visit as a result of observations made during complaint control #: 28-AS-20210824090807. The purpose of the visit was explained to staff Elmer Manalong.

Observations:
  • Staff (S1) was observed in the garage "staff room" hiding in the restroom. Staff does not have Criminal Background Clearance.
  • At 10:37 AM, LPA observed 2 large cockroaches in the kitchen wall. At 11:59 AM, a cockroach was observed on top of the kitchen dining table. Caregiver staff acknowledged there are many cockroaches in the home.

  • The resident beds do not have mattress pads.

  • Discarded stove was observed in the front yard. The exterior sides of the home had discarded mattresses, bed rails, and mattress springs. Trash was observed in the backyard on the floor and trash bins were overfilled with resident incontinence supplies.


Per Title 22 deficiencies are being cited. See LIC 809D.

An exit interview was conducted with staff Elmer Manalong. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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 09/01/2021 02:27 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/01/2021 at 12:51 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 #2
FACILITY NUMBER: 197609098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2021
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
87355(e)(1) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.

This requirement was not met by evidence of:
1
2
3
4
5
6
7
Licensee shall ensure that all staff obtain a Criminal Record Background Clearance prior to starting employment. Uncleared persons cannot return to work until they are cleared and associated to the facility.

Submit proof of Livescan and transfer requests by POC due date (tomorrow).
8
9
10
11
12
13
14
Based on observation during the physical plant inspection of the garage "staff room". Staff (S1) was observed hiding in the restroom. Staff does not have Criminal Background clearance. This poses a potential health and safety threat to residents in care. Civil penalties are being assessed in the amount of $ 500.00.

8
9
10
11
12
13
14
Type B
09/08/2021
Section Cited
CCR87307(a)(3)(C)

1
2
3
4
5
6
7
87307 (a)(3)(C) Personal Accommodations and Services. Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. This requirement was not met by evidence of:
1
2
3
4
5
6
7
Licensee shall purchase mattress pads for all resident beds.

Submit picture proof and receipts by POC due date.
8
9
10
11
12
13
14
Based on observation during the physical plant inspection none of the resident beds had mattress pads in the beds. Staff confirmed mattress pads are not placed on the bed mattresses. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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 Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/01/2021 02:27 PM - It Cannot Be Edited


Created By: Noemi Galarza On 09/01/2021 at 01:40 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 #2
FACILITY NUMBER: 197609098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2021
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement was not met by evidence of:
1
2
3
4
5
6
7
Licensee shall:
1. Remove all discarded equipment and trash from the front/back, and side areas of the home. Provide picture proof of correction.
2. Hire a pest control company and provide proof of weekly treatment for a total of 4 weeks. Submit pest control service in-voice and contract of a minimum of 4 weeks.
8
9
10
11
12
13
14
Based on observation at 10:37 am and 11:59 AM cockroaches were observed in the kitchen area. Staff confirmed there are cockroaches in the home. This poses a potential health and safety issue to residents in care. In addition, discarded stove was observed in the front yard, the exterior sides of the home had discarded mattresses, bed rails, mattress springs, and trash was observed in the backyard.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 Hicks
LICENSING EVALUATOR NAME:Noemi Galarza
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3