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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609604
Report Date: 12/11/2024
Date Signed: 12/11/2024 05:32:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2023 and conducted by Evaluator Erica Mosley
COMPLAINT CONTROL NUMBER: 29-AS-20231222121315
FACILITY NAME:HM SWEET HOMEFACILITY NUMBER:
197609604
ADMINISTRATOR:NADRIAN, ASMIKFACILITY TYPE:
740
ADDRESS:6215 BLUEBELL AVENUETELEPHONE:
(818) 903-6302
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 5DATE:
12/11/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Elena Kordonskiy - AdministratorTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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Resident was left soiled for an extended period of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Erica Mosley conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 12/27/2023 by LPA Teresa Camara. On today's visit at 9:45 a.m., LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. LPA met with Administrator Elena Kordonskiy and explained the reason for the visit. Entrance interview.

On 12/22/2023, the Department received a complaint regarding the following allegation Resident was left soiled for an extended period of time.
During the initial visit on 12/27/2023, LPA Camara conducted a brief physical tour to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations.

REPORT CONTINUED ON LIC 9099-C PAGE 2...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20231222121315
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HM SWEET HOME
FACILITY NUMBER: 197609604
VISIT DATE: 12/11/2024
NARRATIVE
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(PAGE 2) REPORT CONTINUED FROM LIC 9099 ...

On todays visit LPA Mosley conducted a physical plant tour at 9:45 a.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. Interviewed three (3) out of five (5) residents, interviewed two (2) staff including the Administrator, and reviewed and collected relevant documents pertaining to the investigation.

On the allegation Resident was left soiled for an extended period of time it is the concern of the Reporting Party (RP) that the facility staff left Resident #1 soiled for an extended period of time. To investigate this complaint, LPA conducted interviews with three (3) of the five (5) residents. Resident # 1 (R1) was unavailable to interview as they no longer reside at the facility and unavailable to contact. Interviews with two (2) out of three (3) residents revealed that they are not changed on a regular basis and at times can be left soiled. Residents are changed every morning but are not checked on or changed throughout the day. Based on LPA observation at the time of the visit two (2) residents had an odor of feces and were not observed to be changed during the time LPA was present between 9:45 A.M. and 2:20 P.M.. LPA spoke to Administrator about the two (2) residents who smelled of feces and the residents were checked on and changed during the visit. Based on information obtained, there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Resident was left soiled for an extended period of time is deemed substantiated at this time.

Per California Code of Regulations (CCR), Title 22, see LIC 9099-D for deficiencies cited. Exit interview conducted. A copy of the report was issued, along with appeal rights.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20231222121315
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HM SWEET HOME
FACILITY NUMBER: 197609604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2024
Section Cited
HSC
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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The Licensee has agreed to review Regulation 87468.2 and submit a statement of understanding to CCL no later than POC due date.
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Based on observation, the licensee did not comply with the section cited above, as two (2) residents had an odor of feces at the time of the visit indicating residents are not being changed in a timely manner, which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2023 and conducted by Evaluator Erica Mosley
COMPLAINT CONTROL NUMBER: 29-AS-20231222121315

FACILITY NAME:HM SWEET HOMEFACILITY NUMBER:
197609604
ADMINISTRATOR:NADRIAN, ASMIKFACILITY TYPE:
740
ADDRESS:6215 BLUEBELL AVENUETELEPHONE:
(818) 903-6302
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY:6CENSUS: 5DATE:
12/11/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Elena Kordonskiy - AdministratorTIME COMPLETED:
05:35 PM
ALLEGATION(S):
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Staff are not providing adequate food service to residents.
Staff do not make water available to resident.
Staff do not meet personal hygiene needs of resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Erica Mosley conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 12/27/2023 by LPA Teresa Camara. On today's visit at 9:45 a.m., LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. LPA met with Administrator Elena Kordonskiy and explained the reason for the visit. Entrance interview.

On 12/22/2023, the Department received a complaint regarding the following allegations Staff are not providing adequate food service to residents, Staff do not make water available to resident, and Staff do not meet personal hygiene needs of resident.

REPORT CONTINUED ON LIC 9099-C PAGE 2...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20231222121315
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HM SWEET HOME
FACILITY NUMBER: 197609604
VISIT DATE: 12/11/2024
NARRATIVE
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(PAGE 2) REPORT CONTINUED FROM LIC 9099 ...
On todays visit LPA Mosley conducted a physical plant tour at 9:45 a.m. to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. Interviewed three (3) out of five (5) residents, interviewed two (2) staff including the Administrator, and reviewed and collected relevant documents pertaining to the investigation.

On the allegation Staff are not providing adequate food service to residents, it is the concern of the Reporting Party (RP) that the facility serves the same meal for breakfast lunch and dinner. To investigate this complaint the LPA conducted interviews with residents. Resident interviews revealed that Resident #2 (R2) is served the same thing for every meal. Resident stated that they are served oatmeal for all three (3) meals. It was noted that Bananas and Oranges were in the resident’s room however they were provided by the resident’s family and not by the facility. Interview with Resident #3 (R3) revealed that the facility provides meals however they are not to their liking. The resident stated that they do not receive the same thing for all three meals. Interview with Resident #4 (R4) revealed that the food at the facility is not always to their liking, so they purchase their own food. When the food is to their liking, they eat the food the facility provides. Interviews with staff revealed that the food they provide is of good quality and all food groups are offered to the residents. Based on observation the facility has a sufficient amount of perishable food and nonperishable food. During the time of the visit the LPA observed lunch to be served consisting of chicken, rice and salad with juice. The LPA observed Dinner being prepared consisting of salad, vegetable and chicken soup, beef or chicken depending on residents’ choice with rice. The facility plans to provide eggs and oatmeal for breakfast, and vegetable soup with beef or beef with macaroni for lunch. The LPA observed all the required materials that would be needed to prepare the meals. Also, during the 12/27/2023 inspection, LPA Camara observed a sufficient amount of perishable and non-perishable food. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff are not providing adequate food service to residents is deemed unsubstantiated at this time.
REPORT CONTINUED ON LIC 9099-C PAGE 3...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20231222121315
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HM SWEET HOME
FACILITY NUMBER: 197609604
VISIT DATE: 12/11/2024
NARRATIVE
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(PAGE 3) REPORT CONTINUED FROM LIC 9099 PAGE 2...

On the allegation Staff do not make water available to resident, it is the concern of the Reporting Party (RP) that the facility does not make water readily available to residents. To investigate this complaint LPA conducted interviews with residents. Resident interviews revealed that water is made available to residents and is readily available. Residents have no concerns with water being available to them. Staff interviews revealed that water is always made available to residents. During today’s visit and the 12/27/2023 visit, the LPA's observed multiple water bottles in all resident rooms. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not make water available to resident is deemed unsubstantiated at this time.

On the allegation Staff do not meet personal hygiene needs of resident, it is the concern of the Reporting Party (RP) that Resident #1 (R1) had feces left under their fingernails. To investigate this complaint LPA conducted interviews with residents. Resident # 1 was unavailable to interview as they no longer reside at the facility and unavailable to contact. Resident interviews revealed that their personal hygiene needs are being met as they are showered on a regular basis. R2 is bathed on a regular basis. R3 has refused showers recently due to not having to get an ear infection, however the service is available. Residents had no concerns with their personal hygiene needs not being met. Staff interviews revealed that they were unaware that R1 had feces under their nails. Staff state they do their best to ensure that all residents personal hygiene needs are met. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not meet personal hygiene needs of resident is deemed unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued, along with appeal rights.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6