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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609098
Report Date: 10/20/2022
Date Signed: 10/21/2022 09:57:19 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
PUBLIC
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: 6DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
02:14 PM
MET WITH:Tina Arutyunyan/Elmer Manalang - caregiverTIME COMPLETED:
03:48 PM
ALLEGATION(S):
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Resident is being over medicated while in care
INVESTIGATION FINDINGS:
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This report serves as an addendum and supersedes the complaint investigation report created on 7/14/22. This addendum is written to correct and add 2 deficiencies on LIC 9099D and does not change the complaint investigation report findings recorded on 7/14/2022. Subsequent visit on 10/20/2022

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. (Continued on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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 5
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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SKYHILL QUALITY LIVING #2
FACILITY NUMBER: 197609098
VISIT DATE: 10/20/2022
NARRATIVE
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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:

Medication Sertraline medication 50MG had 36 pills uncounted for based on count. Medication Monteluska 10mg 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.

Deficiencies cited on 809D

Based on LPA observations, interviews and records review, the preponderance of evidence standard has been met; therefore, the Allegation above is Substantiated

Exit interview conducted with Administrator via phone and report signed with prior approval of Administrator by Elmer Manalang, Caregiver. Copy of report emailed to administrator due to printer issues.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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:
10/20/2022
UNANNOUNCEDTIME BEGAN:
02:14 PM
MET WITH:Tina Arutyunyan/Elmer Manalang - caregiverTIME COMPLETED:
03:48 PM
ALLEGATION(S):
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9
Facility is not ensuring that resident receives medical attention for skin issues.
INVESTIGATION FINDINGS:
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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 violation did or did not occur; therefore, the complaint investigation of the allegation is unsubstantiated.

Exit interview conducted with Administrator via phone and report signed with prior approval of Administrator by DSP staff Elmer Manalang, Caregiver. Copy of report emailed due to printer issues.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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 5
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
GREATER LA AC/SC, 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: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2022
Section Cited
CCR
87465(e)
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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 by:
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Licensee will obtain doctor's orders for all of R1 medications and PRN letters and send proof to LPA by POC date.

****Licensee provided proof of PRN letter to LPA for R1**** NO FURTHER ACTION REQUIRED**
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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 missing label and doctor's order which poses a health and safety issue to residents in care.
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Type A
10/21/2022
Section Cited
CCR
87465(h)(5)
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to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidence by:
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Licensee will provide training on proper medication storage and administration and send proof that all staff have attended the training by POC date
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Staff stated that he transfers the new refill medications to the old bottles to consolidate the medications which poses a health and safety issue to residents in care.
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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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
GREATER LA AC/SC, 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: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.


This requirement is not met as evidence by::
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Licensee will conduct training in personal rights for all staff and send proof to LPA by POC date.
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Staff provided medications to resident without keeping log which resulted in medications being short. Medication Sertraline medication 50MG had 36 pills uncounted for based on count. Medication Monteluska 10mg had 31 pills missing and unaccounted for. Tamsulin medication .4mg had 5 pills missing. Caregiver could not account for the missing pills which poses a health and safety issue to residents in care.
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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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5