197607711-9-28-2023-31-AS-MCAA-CW4UAV-20230928152522

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607711
Report Date: 09/28/2023
Date Signed: 09/28/2023 03:25:28 PM

Document Has Been Signed on 09/28/2023 03:25 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:	OUR SWEET HOME INC		FACILITY NUMBER:	197607711
ADMINISTRATOR:	ARUTYUNYAN, TINA		FACILITY TYPE:	740
ADDRESS:	16518 DEVONSHIRE ST		TELEPHONE:	(818) 970-9586
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 5	DATE:	09/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:46 PM
MET WITH:	Tina Arutyunyan, Norma Alfeche, Manual Soriano		TIME COMPLETED:	03:30 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	Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Huma Rahimi and Michael Cava conducted an Annual Required visit and inspection of the facility. LPAs met with the administrator, Tina Arutyunyan, and staff Norma Alfeche and Manual Soriiano and explained the reason for the visit. At approximately 12:46pm, with the assistance of staff, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are battery operated. The carbon monoxide detector, that is installed in the dining room, functions properly. The fire extinguisher is located in the kitchen. It was purchased on September 12, 2023. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There were five (5) bedrooms designated for residents' use. Room #5 is a shared room. Rooms 1 to 4 are private. LPAs observed rooms that are occupied by the residents to be properly furnished with appropriate beddings and linens and sufficient lighting. Room #3 is currently vacant. There is one room, designated for staff use. Bathrooms: There are three (3) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 110 and 111 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were tested and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: OUR SWEET HOME INC	FACILITY NUMBER: 197607711
	VISIT DATE: 09/28/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. The laundry area is located by the living room. Detergents and cleaning supplies were kept locked.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for storage and documentation. documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2023 03:25 PM - It Cannot Be Edited

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: OUR SWEET HOME INC	FACILITY NUMBER: 197607711
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(c)(2)

Incidental Medical and Dental Care Services

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [two] out of [ two ] Resident's medication, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	As POC, licensee will conduct staff training to address this section of the regulations. As proof training was made, licensee will submit a training log with attendance sheet to the licensing agency by 10/05/23.

Type A

Section Cited

CCR

87465(d)(3)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [two] out of [ two ] Resident's medication, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	As POC, licensee will conduct staff training to address this section of the regulations. As proof training was made, licensee will submit a training log with attendance sheet to the licensing agency by 10/05/23.

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	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC809 (FAS) - (06/04)

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