197608084-3-18-2025-31-AS-APAA-DEVQJ5-20250318121210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608084
Report Date: 03/18/2025
Date Signed: 03/18/2025 12:12:52 PM

Document Has Been Signed on 03/18/2025 12:12 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 #3		FACILITY NUMBER:	197608084
ADMINISTRATOR/ DIRECTOR:	ARUTYUNYAN, TINA		FACILITY TYPE:	740
ADDRESS:	21054 VINTAGE ST		TELEPHONE:	(818) 960-5224
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	03/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Tina Arutyunyan, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

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At 9:30am, Licensing Program Analysts (LPAs) Angela Panushkina and Huma Rahimi arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPAs met with the Staff #1 who granted access to the facility. Administrator arrived shortly after, and LPAs explained the reason for the visit.

At 9:35am LPAs conducted a tour of the physical plant and observed the following:

Facility is licensed for capacity of six (6) of which five (5) may be Non-Ambulatory and one (1) bedridden residents. Facility also has a hospice waiver for four (4) residents. There are five (5) bedrooms designated for residents’ use, and one (1) bedroom, located by the kitchen area, is designated for live-in caregivers. Facility maintains a temperature of 75°F. LPAs observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All knives were observed to be locked in the kitchen drawer. The fire extinguisher is located in the dining area and was last serviced on 9/24/2024. Medications and resident/staff files are kept in a metal cabinet, located in the dining area and kept locked and inaccessible to residents in care. There is a complete first-aid kit in the cabinet with all required supplies and with the first aid manual. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. Bathrooms have soap, paper towels and all trash cans have a lid. Extra towels and linens were readily available. The hot water temperature measured at 113.5°F. Laundry is located in the garage. The washer/dryer appear to be in good condition. Laundry supplies, chemicals and detergents are kept in the garage and inaccessible to residents in care. Smoke detectors and carbon monoxide monitors were tested at 10:00am and observed to be functional. At 10:20am, LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. LPAs also observed sufficient yard space with fenced backyard. The outdoor area was free of visible immediate hazards. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents.
Continue on LIC809-C

Nichelle Gillyard	TELEPHONE: (818) 596-4341
Angela Panushkina	TELEPHONE: 747-230-3364
	DATE: 03/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025

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 #3	FACILITY NUMBER: 197608084
	VISIT DATE: 03/18/2025

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There is a swimming pool that is fenced with a gate that will be kept locked at all times. The fence installed to keep residents out of the swimming pool area is approximately 5 feet high throughout the parameters. You will need a key to unlock the padlock to gain entry to the swimming pool as it is kept locked at all times. Between 10:50am to 11:30am, LPAs reviewed records of five (5) residents and two (2) staff. Resident and staff records appeared to be complete and updated. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentarians. LPAs were informed that the facility is no longer responsible for residents P&I Records.

LPAs collected Certificate of Liability Insurance, Administrator Certificate and LIC500.

No citations issued during this visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025

LIC809 (FAS) - (06/04)

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