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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609098
Report Date: 07/14/2022
Date Signed: 07/14/2022 04:16:11 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2022 and conducted by Evaluator Alberto Lopez
COMPLAINT CONTROL NUMBER: 28-AS-20220712085123
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: 5DATE:
07/14/2022
UNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Elmer Manalang, CaregiverTIME COMPLETED:
04:24 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident is being over medicated while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
A complaint investigation was conducted by LPA Alberto Lopez at the time of the visit, LPA met with Elmer Manalang Caregiver and explained the purpose of the visit. Elmer stated that Administrator was out of the country.

LPA reviewed medications and medication records for Resident #1. LPA also conducted an interview with R1-R2 and R3. R4 and R5 could not answer questions. Based on interviews and medication record review, LPA observed the following: Resident's #1's medication Ativan is labeled as a PRN and caregiver stated he gives one every night to resident because resident ask for. R1 is clear and oriented and stated he does not ask for it every day. Caregiver stated it is to help him sleep. LPA reviewed medications and caregiver Elmer stated that he empties old bottle into new bottle whenever the resident gets new refills. Based on that, there were pills missing from: (cont on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 28-AS-20220712085123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/15/2022
Section Cited
CCR
87465(e)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental: (e) For every prescription and nonprescription PRN medication... there shall be a signed, dated written order from a physician,... maintained in the residents file, and a label on the medication....
This requirement is not met as evidence
1
2
3
4
5
6
7
Licensee will obtian doctor's orders for all of R1 medications and PRN letters and send proof to LPA by POC date.
8
9
10
11
12
13
14
None of R1 medications had doctor's orders and PRN physician letter was not on file for R1 PRN medications. Cream for skin rash was missiing label and doctor's order.
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.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2022 and conducted by Evaluator Alberto Lopez
COMPLAINT CONTROL NUMBER: 28-AS-20220712085123

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: 5DATE:
07/14/2022
UNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Elmer Manulang, CaregiverTIME COMPLETED:
04:24 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not ensuring that resident receives medical attention for skin issues.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Regarding the above allegation: R1 has rash on his back. Physician report dated 6/16/22 states that resident has had history of skin issues. R1 and caregiver both stated that cream is applied to his back on daily basis. The facility is addressing this issue.


Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violationn did or did not occur; therefore, the complaint investigation of the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20220712085123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/14/2022
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
26
27
28
29
30
31
32
Medication Sertraline medication 50MG had 36 pills uncounted for based on count. Medication Monteluska 10mg had had 31 pills missing and unaccounted for. Tamsulin medication .4mg had 5 pills missing. Caregiver could not account for the missing pills. Caregiver stated he did not throw them away. Facility does not have any documentation to keep track of medications given. All of R1 medication is missing doctor;s order and PRN is missing physicians letter.


Based on LPA’s observations, interviews and records review, the preponderance of evidence standard has been met; therefore, the Allegation above is Substantiated
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4