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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610270
Report Date: 12/31/2024
Date Signed: 12/31/2024 01:07:08 PM

Document Has Been Signed on 12/31/2024 01:07 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:SKYVIEW ASSISTED LIVINGFACILITY NUMBER:
197610270
ADMINISTRATOR/
DIRECTOR:		HULSE, BREANNAFACILITY TYPE:
740
ADDRESS:18761 BIG CEDAR DRIVETELEPHONE:
(661) 965-4652
CITY:SANTA CLARITASTATE: CAZIP CODE:
91387
CAPACITY: 6CENSUS: 2DATE:
12/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Glen Huse- CEOTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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
On 12/31/2024 at approximately 09:30 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. Upon arrival LPA was greeted by Caregiver Rachel Langan. LPA stated the reason for their visit. The Facility Representative Glen Hulse arrived shortly after to assist with today’s visit.

LPA asked for census, staff, and resident files. LPA conducted a physical plant tour at approximately 10:30 AM and the following was noted:

There is only one entrance being utilized at the facility. The facility is a single unit building with four (4) bedrooms and two and a half (2.5) bathrooms currently occupying two (2) residents. No designated staff room.

Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. Required postings such as See/Say Something, Long-Term Ombudsman, and Resident’s Rights were located alongside entrance.

Common areas: Living room and dining room observed to be neat, clean, and organized. Common areas observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 76°F. Fire extinguisher located near the sliding door leading towards the backyard and dated 12/31/24. Electric fireplace observed to be covered and located in the living room inaccessible to residents. Working telephone located in living room.

The kitchen observed to be fully stocked with two (2) days perishable and seven (7) days non-perishable food. Kitchen observed to be clean and inaccessible to pests. Knives and sharps observed to be locked in a locked box located on top of kitchen counter and inaccessible to residents. (continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
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
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: SKYVIEW ASSISTED LIVING
FACILITY NUMBER: 197610270
VISIT DATE: 12/31/2024
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
The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. There is no body of water in this facility.

Smoke detectors and carbon monoxide observed to be working properly and were tested. Quarterly Emergency drill has not been completed and/or documented.

The laundry room is located near the garage. Laundry detergents, cleaning agents, and other toxins are stored within laundry room and are locked inaccessible to residents. Sufficient availability of clean lien stored in laundry room cabinets. The laundry room then leads to a staff office containing resident and staff files kept locked in a filing cabinet. The garage is being used for extra storage, staff break room, and extra supply of cleaning solutions/toxins. The garage can be accessed from inside the facility and kept locked inaccessible to residents.

The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Residents have sufficient personal hygiene product which is provided by the licensee. The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured at a range of 111.9 - 114.6°F. Towels and washcloths are not shared. Appropriate grab rails and skid mats were observed and in proper condition.

Medications: LPA observed medication stored in kitchen cabinet locked and inaccessible to residents. Medication usage recorded and stored properly. LPA along with caregiver Langan conducted a review of the medication to ensure compliance. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and manual.

Resident records: LPA conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be incomplete. Administrator and complete staff files missing and/or not readily available for LPA record review.

An exit interview was conducted, two (2) citations issued for Personnel Record availability and Emergency Drill not being readily available and/or completed. Appeals rights and a copy of this report was given to Facility Representative Hulse.

Administrator and/or Licensee will email LPA Segovia a copy of their complete Personnel Records and Emergency Drill by 1-14-2025.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 12/31/2024 01:07 PM - It Cannot Be Edited


Created By: Angelica Segovia On 12/31/2024 at 12:36 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: SKYVIEW ASSISTED LIVING
FACILITY NUMBER: 197610270

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above. The licensee failed to ensure that all personnel files are in the facility. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2025
Plan of Correction
1
2
3
4
 The Administrator will email LPA Segovia a written statement of understanding that all personnel records, including that of the administrator must be retained in the facility on or before the POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation aand record review, the licensee did not comply with the section cited above in no documenation of quarterly emergency drill being conducted which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2025
Plan of Correction
1
2
3
4
Administrator will conduct fire drills once every three months. Administrator will set quarterly reminders by posting a fire drill calendar as a reminder. Administrator will provide LPA proof of the an updated Fire/Disaster Drill signed and dated by staff by 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:Troy Agard
LICENSING EVALUATOR NAME:Angelica Segovia
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3