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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608084
Report Date: 04/12/2024
Date Signed: 04/12/2024 01:50:23 PM


Document Has Been Signed on 04/12/2024 01:50 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:OUR SWEET HOME INC #3FACILITY NUMBER:
197608084
ADMINISTRATOR:ARUTYUNYAN, TINAFACILITY TYPE:
740
ADDRESS:21054 VINTAGE STTELEPHONE:
(818) 960-5224
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 5DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Saturnina Reyes - StaffTIME COMPLETED:
02:25 PM
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At 12:30am, Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPAs met with Staff #1, who granted access to the facility. LPAs explained the reason for the visit.

At 12:45am 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. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. The hot water temperature measured at 114.0°F. Extra towels and linens were readily available. During the LPAs did not observe any immediate health and safety concerns. Facility maintains a temperature of 73°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. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. The fire extinguisher was observed in the kitchen area and was last purchased on 09/12/2023. Laundry is located by the kitchen, and LPAs observed all chemicals and detergents are kept locked and inaccessible to residents in care. LPAs observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Smoke detectors and carbon monoxide monitors were tested at 1:20pm and observed to be functional. Between 1:30am to 2:00pm, LPAs reviewed records of five (5) clients and two (2) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit.
Exit interview conducted and copy of this report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Perchui KhurshudyanTELEPHONE: (818) 439-7073
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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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