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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609098
Report Date: 04/18/2022
Date Signed: 12/22/2022 04:15:19 PM

Document Has Been Signed on 12/22/2022 04:15 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:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Elmer Manalang, Care giver TIME COMPLETED:
10:20 AM
NARRATIVE
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Licensing Programming Analysts (LPA) Jewel Baptiste conducted and unannounced visit with focus on infection control, food and medication review. LPA met with caregiver Elmer Manalang and explained the reason for our visit. LPA also spoke to Administrator Tina Arutyunyan and explain the reason for the 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 throughout the facility.

LPAs and Caregiver toured the facility: Bedrooms #1(R1), #2, #3 and #4 was observed to have all the furnishings of 1 desk, chair, lamp and linens. Bathroom #1 toilet has stains and rings of yellow and brown color. Bathroom #2 shower contained dark stains throughout. Caregiver stated he purchased paint for toilet and tub. Bathroom #3 designated for staff only. Water temperature was tested in Bathroom#1 at 114.6, and Bathroom #2 at 115 , which is within the required 105-120 degrees F. LPA toured the kitchen and observed sufficient food supplies of 7 days non-perishables and 2 days perishable. LPA toured the backyard with caregiver and observed laundry detergent and cleaning supplies place on the floor next to washer and dryer. LPA also observed mattress, box spring and other trash on the side of the house. Caregiver confirmed that theey have tried to get the items removed. Medication was reviewed for Residents #1, #2 #3, #4, #5 and #6. LPA observed 2 of R6 medications empty. Caregiver confirmed medications has been empty for a week and resident usually calls and update his prescription.


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: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2022 04:15 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 04/18/2022 at 11:50 AM
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: 04/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintanence services and procedures for the safety and well-being of the 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 #1 and #2 toilet and tub was observed with not clean and in good repair. LPA also observed Mattress, box spring and trash located at the side of the house, which poses an potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2022
Plan of Correction
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Licensee will ensure Bathrooms toliet and showers are cleaned and good repair. Licensee will also removed bed, box spring and trash on the side of the house. Licensee will submitt pictures of repaired/clean toilets by POC date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/22/2022 04:15 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 04/18/2022 at 12:02 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: 04/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)

(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 poisions, 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 disinfectants, cleaning solutions and laundry detergent were not locked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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Licesee will ensure disinfectants, cleaning solutions and laundry detergent is in a locked storage. Licensee will provide staff training and signin sheet is due to LPA by POC date. The deficency was corrected during the visit.
Type A
Section Cited
CCR
87465(c)(2)

(c) If the resident's physican has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physcian the medication is givengiven according to the physcian's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as R1 medications has not been administered for aprox. 1 week, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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Licensee shall ensure R1 is given his medications as directed in physcians orders. Licensee provide staff training on section 87465 and a copy of sign in sheet is due to LPA by POC date.
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:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 #2
FACILITY NUMBER: 197609098
VISIT DATE: 04/18/2022
NARRATIVE
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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/ Tina Arutyunyan over the phone and a copy of this report, LIC809D and appeals rights was provided to caregiver.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC809 (FAS) - (06/04)
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