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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609909
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:10:57 PM

Document Has Been Signed on 12/09/2021 02:10 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SKY LIGHT RESIDENTIAL CAREFACILITY NUMBER:
197609909
ADMINISTRATOR:PODRUMYAN, MAROFACILITY TYPE:
740
ADDRESS:19856 MAYALL STREETTELEPHONE:
(818) 945-8301
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 1DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Maro Podrumyan, AdministratorTIME COMPLETED:
02:20 PM
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On 12/9/21 at 12:34pm, Licensing Program Analyst(LPAs) Shira Stamps and Melissa Ruiz met with administrator Maro Podrumyan for an unannounced one (1) year required visit for this facility.

LPAs arrived at 12:34pm and were greeted by caregiver Nelli Tovasyan. One (1) resident was observed in their room watching TV. The Administrator Maro Podrumyan arrived approximately at 1:00pm. LPAs informed the Administrator of the purpose of the visit.

Infection control: LPA Stamps reviewed facility mitigation plan (approved on 04/02/21) to make sure the Administrator was following current infection control recommendations. Upon arrival the LPAs were not screened by the caregiver Nelli Tovasyan, and no infection control questions were asked. LPAs were not asked to sign-in and sanitize/wash hands.

A tour of the physical plant was conducted with the Caregiver at 12:34pm. The facility has six (6) bedrooms and three and a half(3 1/2) bathrooms currently occupying One (1) resident. One (1) bathroom and one(1) bedroom is designated for staff use only. The facility is Fire Cleared for six(6) bedridden, and a hospice wavier for four(4).

Resident Rooms
LPAs observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each bedroom.

Bathrooms
At 12:45pm LPAs observed all bathrooms to have non-skid matts, grab bars, and paper towels. Hot water was tested at 1:20pm and measured within regulation at 105.3 degrees F.
Continued.....
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SKY LIGHT RESIDENTIAL CARE
FACILITY NUMBER: 197609909
VISIT DATE: 12/09/2021
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Laundry
LPAs observed chemicals/hazardous items in a locked cabinet in the laundry room.

Food Inspection
LPA Stamps conducted a tour of the kitchen around 12.34pm and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are care clean and inaccessible to pests. LPAs observed all knives and sharp object being locked and inaccessible to residents in care. At 12:44pm LPAs observed an unlocked cabinet of chemicals/hazardous items.

Physical environment
LPAs toured the outside area of the facility at 12:55pm. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a body of water on the premises. LPAs observed the gate locked and inaccessible to residents.

Living and dining
LPAs observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 73°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 1:28pm. There is one (1) fire extinguisher, located near the kitchen. Fire extinguisher was observed to be full and last serviced on 02/03/21. Medications were located in the hallway cabinet and at 12:50pm; was observed to be locked and inaccessible to residents in care.
Garage
LPAs observed no garage for the facility. PPE supplies are stored in the hallway closet.

Administrative: Annual fee is current.


An exit interview was conducted, and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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Document Has Been Signed on 12/09/2021 02:10 PM - It Cannot Be Edited


Created By: Shira Stamps On 12/09/2021 at 01:44 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: SKY LIGHT RESIDENTIAL CARE
FACILITY NUMBER: 197609909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)
87468.1(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 evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above due to the staff not following the infection control mitigation plan which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2021
Plan of Correction
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The Administrator agreed to provide in house training, provide training materials and proof of sign in sheet for staff to the LPA by e-mail. Additionally, Administrator will ensure the use of a visitation log and send proof to LPA by POC due date.
Type A
Section Cited
CCR
87309(a)
87309 Storage Spacem (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.

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 due to cleaning supplies being accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2021
Plan of Correction
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Administrator has agreed to provide in house training and provide training materials regarding this regulation to LPA by e-mail by the POC due 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


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