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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609098
Report Date: 11/30/2021
Date Signed: 11/30/2021 04:09:41 PM

Document Has Been Signed on 11/30/2021 04:09 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:
11/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Elmer Manalang - Caregiver TIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Programming Analysts(LPAs) Mary Flores and Jewel Baptiste conducted and unannounced visit with focus on infection control, food and medication review. LPAs met with caregiver Elmer Manalang and explained the reason for our visit.

Facility is licensed to serve 6 over the age of 60 of which 6 is non-ambulatory and 2 can be bedridden. Hospice waiver approved for 2 residents. Facility is a one story house with a Living room, dining room, kitchen, 4 bedrooms and 3 bathrooms. Facility has multiple fire extinguishers, carbon monoxide detectors with sprinkler system through out the facility.

LPAs and administrator toured the facility: Bedrooms #1(R1), #2, #3 and #4 was observed to have all the furnishings of 1 desk, chair, lamp and linens. PRN medication was observed in R1 belonging to resident #4. Bathroom #1 toilet has stains and rings of yellow and brown color. Bathroom #2 shower contained dark stains throughout. Bathroom #3 toilet bedside commode was rusted. Water temperature was tested in Bathroom#1 at 152.3, Bathroom #2 at 155.5 and Bathroom #3 at 145.5, which is not within the required 105-120 degrees F. LPAs toured the kitchen and observed sufficient food supplies of 7 days non-perishables and 2 days perishable. LPAs also observed knives in a drawer to the right of the kitchen's sink and chemical solutions for cleaning and pest sprays were located under the sink and a small drawer without a lock. Medication cabinet was observed unlocked. Medication was reviewed for Residents #1, #2 and #3.
Facility was observed not following COVID-19 recommendations of screening staff, residents and visitors. Screening needs to be updated to include all COVID symptoms questions and hand washing guidance's. Upon arrival staff was observed not wearing a face covering, Staff need to get fit tested and facility must provide closed lids trash can.
Deficiencies was observed during this visited and noted on LIC809D, per California code of regulations, Title 22. Exit interview was conducted with Caregiver Elmer Manalang and a copy of this report, ,LIC809D and appeals rights was provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2021
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 12
Document Has Been Signed on 11/30/2021 04:09 PM - It Cannot Be Edited


Created By: Mary G Flores On 11/30/2021 at 02:55 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: 11/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 3 out of 3 bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2021
Plan of Correction
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Licensee will ensure water temperature is maintain within the required range of 105-120 degress F. at all times. Licensee will certify and submit LIC 9098 by 12/1/2021. Licensee will maintain log for 7 days and submit to the department on 12/7/2021.
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as knives and chemical solutions were not in a locked storage, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2021
Plan of Correction
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Licensee will provide a lock space for knives and sharps, and will ensure knives and chemical solutions are kept lock at all times. Licensee will provide in-service training, submit pictures of locked space and cabinet, and copies of in-service training agenda and sign-in sheet by 12/1/21.
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:Rebecca Orendain
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 11/30/2021 04:09 PM - It Cannot Be Edited


Created By: Mary G Flores On 11/30/2021 at 02:55 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: 11/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as medications was observed unlocked, refill medication was in an unlocked drawer in the kitchen and PRN medication was observed in resident #1 bedside table, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2021
Plan of Correction
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Licensee will ensure medications are kept locked at all times. Licensee will provide in-service training to staff and submit a copy of the training agenda and sign-in sheet by 12/1/21.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Rebecca Orendain
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 11/30/2021 04:09 PM - It Cannot Be Edited


Created By: Mary G Flores On 11/30/2021 at 02:55 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: 11/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as bathroom and showers were not observed clean which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2021
Plan of Correction
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Licensee will ensure bathrooms, showers and toilets are kept clean and in good repair. Licensee will submit pictures of repaired/cleaned toilets and replaced commode toilet seat by 12/8/21
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Rebecca Orendain
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2021


LIC809 (FAS) - (06/04)
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