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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609098
Report Date: 12/02/2022
Date Signed: 12/02/2022 03:36:34 PM

Document Has Been Signed on 12/02/2022 03:36 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
GREATER LA AC/SC, 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:
12/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Tina Arutyunyan TIME COMPLETED:
03:44 PM
NARRATIVE
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LPA Alberto Lopez made unannounced case management visit to facility to follow-up on office visit of 04/26/2022 LPA met with Administrator Tina Arutyunyan and discussed the purpose of the visit .

LPA took tour of the 4 bedrooms and outside plant All the rooms had the required furniture and were clean. LPA measure the water temperature in 3 bathrooms and kitchen and it measured 107.6 in Bathroom #1 sink, tub in room #1 was 88.0 degrees, In bathroom #2, temperature was 87.2 Bathroom #4 and kitchen measured at 87.2. Bathroom in room #4 is uncleaned on the window sill and the screen is in disrepair and need too be repair or replaced. LPA reviewed P & I Logs for 2 residents and it was in order. 7 days of Non-perishable and 2 days of perishable food were observed, 1 bedridden residents was in room not designated for bedridden. Administrator has clearance for 2 bedridden residents in room #1 only. Administrator notified fire department on Tuesday 11/29/2021 - Danny King about getting bedridden fire clearance for 6 residents . It was discussed with R1 and administrator that R1 needs to move to room #1 unless his MD designates R1 as Non-ambulatory or fire clearance is granted to facility.


deficiencies cited (see 809D for details)

Exit interview was conducted with Administrator Tina Arutyunyan and copy of report and appeal rights provided.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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 12/02/2022 03:36 PM - It Cannot Be Edited


Created By: Alberto Lopez On 12/02/2022 at 02:24 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: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/02/2022
Section Cited
CCR
87303(e)(2)

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87303 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 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
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Administrator will adjust water temperture and provide proof to LPA by POC date.
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Based on LPA's observation, LPA observed the bathroom #1 hot water temeperature was measured at 88.5 degrees Fin the tub. Siink in room #1 was 107.6. Bathroom 2 measured at 88.5, bathroom Room #4 measured at 87.2 and kitchen ,easured at 87.2 which poses a health and safty hazard to resident's in care.
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Type B
12/09/2022
Section Cited
CCR87303(a)

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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:

This requirement is not met as evidenced by:
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Administrator will reapair or replace screen in bathroom number 4 and clean window sill and toilet by POC date
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LPA and Administtrator observed bathroom screen in disrepiar and window sill uncleaned and toleit uncleaned.

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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:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/02/2022 03:36 PM - It Cannot Be Edited


Created By: Alberto Lopez On 12/02/2022 at 02:51 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: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2022
Section Cited
CCR
87202(a)(2)

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Licensee admitted residents that became bedridden resident #1(R1) . Facility does have approved bedridden clearacne for 2 residents but must be in room
#1 fire clearance.is required before bedridden residents can reside in any other room other than room #1

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Licensee shall submit appropriate request for bedridden fire clearance. Or move resident to room #1 or get updated Physicans report.

LIC200, facility floor plan and plan of care for bedridden residents must be submitted to CCL by POC due date.
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This requirement is not met as evidenced by:

R1 is bedridden and residing in room #4 which is not cleared for bedridden which poses a helath and safety issue to persons 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.
SUPERVISOR'S NAME:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2022


LIC809 (FAS) - (06/04)
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