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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609098
Report Date: 03/19/2025
Date Signed: 03/19/2025 03:09:23 PM

Document Has Been Signed on 03/19/2025 03:09 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SKYHILL QUALITY LIVING #2FACILITY NUMBER:
197609098
ADMINISTRATOR/
DIRECTOR:		ARUTYUNYAN, TINAFACILITY TYPE:
740
ADDRESS:626 N LAMER STTELEPHONE:
(818) 558-5971
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 6CENSUS: 3DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:36 AM
MET WITH:Tina Arutyunyan-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:57 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced Required - 1 Year annual inspection visit. Upon arrival at 8:30am, LPA met with Tina Arutyunyan-Administrator and explained the purpose of the visit. Facility is licensed for six (06) non-ambulatory residents with a hospice waiver for four (04). Current census is three (3) residents, two (2) of them are non-ambulatory.

LPA toured the facility with the Administrator at 10:10 am and observed the following:

Required postings were observed by the living room and office areas. The front entry is the main exit door with four (4) additional exits (the kitchen, bedrooms #1, 2, and 3) leading to the backyard. The physical plant appeared clean, sanitary and with no visible immediate hazards. There are two (2) fire extinguishers, one (1) in the kitchen, one (1) in the office/living room. Both fire extinguishers were fully charged on 01/23/2025. Facility conducts quarterly fire and safety drills; the last fire drill was conducted on 02/052025. The dual smoke alarms and carbon monoxide detectors are hardwired and interconnected, in addition facility is equipped with fire sprinklers in every room. Smoke/carbon monoxide alarms are tested by the Burbank Fire Department annually, the last inspection was on 01/23/2025.

Continued on 809-C

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SKYHILL QUALITY LIVING #2
FACILITY NUMBER: 197609098
VISIT DATE: 03/19/2025
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Common Areas: Include a living room with television and gaming area, dining area in the kitchen. The office area is located near the living room. The living room had a table and ample sitting for all the residents and staff.

Kitchen: There are two (2) refrigerators, stove, macro wave, dishwasher in the kitchen with a dining table/chairs for six clients. Knives, cutlery and other sharp kitchen utensils are stored and locked in the kitchen cabinet. Food storage and preparation areas are clean and sanitary. LPA found a sufficient amount of perishable food supplies for two (2) days and non-perishable food supplies for seven (7) days in the kitchen.

Bathrooms: There are three (3) full bathrooms for the residents. All toilets and sinks are maintained in sanitary, operating condition. Functional grab bars and non-slip mats were observed in resident bathrooms. Hot water temperature was tested between 109 - 110.3 degrees Fahrenheit.

Bedrooms: There are four (4) bedrooms for resident use. Bedrooms #1 and #2 are private with their own bathroom and exit doors. Bedroom #3 has an exit door and bedroom# 4 has its own bathroom and exit door. All of the bedrooms were properly furnished with appropriate chairs, beddings, chest drawers, linens with sufficient lighting. LPA observed call buttons in each bedroom. LPA pushed the call button in rooms #3 and #4 and staff responded to call buttons within two (2) minutes.

Surrounding grounds: Entry/exit gates and pathways were free of obstruction. The outdoor area was free of visible immediate hazards. No bodies of water were observed at the facility. There is a shaded patio area in the front yard, with furniture appropriate for outdoor use, sufficient for all clients. Facility has a detached garage with a bathroom which currently is used for staff use only. Laundry machines were located in the backyard and were recently purchased a month ago. All laundry detergents/chemicals are stored in a cabinet in the laundry area. LPA observed the cabinet for the chemicals to be unlocked. A citation will be issued for health and safety issue.

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SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SKYHILL QUALITY LIVING #2
FACILITY NUMBER: 197609098
VISIT DATE: 03/19/2025
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Medications: The medication are centrally stored and locked in the kitchen cabinet. LPA observed a complete first-aid kit in the office area, with all required supplies and the first aid manual. Medication records for three (3) residents were reviewed and counted for accuracy of administration based on physician orders. LPA observed several supplements and medications for the staff, in an unlocked kitchen drawer. A citation will be issued for health and safety issue.

Resident Files: A review of resident records to ensure compliance of licensing forms was conducted.

Staff Files: Staff files were reviewed to ensure all forms and training certificates are up to date.

Pursuant to Title 22 Division 6 of the CA Code of Regulations deficiencies were observed during the visit and citations were issued with appeal rights. Staff immediately corrected the deficiencies; Administrator will ensure that staff are retrained and will submit proof of correction to LPA.

Exit Interview Conducted / A Copy of the Report provided to Administrator.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/19/2025 03:09 PM - It Cannot Be Edited


Created By: Nadia Shahbazian On 03/19/2025 at 02:17 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SKYHILL QUALITY LIVING #2
FACILITY NUMBER: 197609098

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 ensuring that laundry cleaners/chemicals are kept in locked cabinets, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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In-service training will be also provided to all current and future staff members. Licensee/Administrator will retrain the staff and will submit in writing, copy of the training to the LPA/Department by POC date.
Type B
Section Cited
CCR
87309(c)
Storage Space and Access
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents.

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 ensuring that medications and supplements are kept in locked cabinets, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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In-service training will be also provided to all current and future staff members. Licensee/Administrator will retrain the staff and will submit in writing, copy of the training to the LPA/Department 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:Eva Miller
LICENSING EVALUATOR NAME:Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


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