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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 11/08/2023
Date Signed: 11/08/2023 03:59:50 PM


Document Has Been Signed on 11/08/2023 03:59 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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: 4DATE:
11/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Mariam BaghdoyanTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA Yee) conducted an unannounced case management visit due to deficiencies noted on a visit to the facility today. LPA Yee met with Mariam Baghdoyan, Caregiver. Also present during the visit was Emilya Hovsepyan, Caregiver. The Administrator was unreachable during today's visit. The reason for today's visit was explained.

During today's visit, staff attempted to contact the Administrator/Licensee, Asmik Nadrian via telephone and she was unreachable. The following deficiencies were observed:
  • Staff files were reviewed and there was no completed LIC308 - Designation of Facility Responsibility observed in file for the 2 staff present at the facility to provide coverage when the Administrator is not present at the facility. A completed LIC308 was observed in for Marine Arshakyan but she was not present at the facility today until 1:20pm.
  • LPA Yee requested Mariam Baghdoyan's file and was not able to be located or produced for review until 2:52pm and it was incomplete. It contained the LIC508-Criminal Record Statement, LIC9182 Criminal Background Clearance Transfer, LIC503-Health Screening Report - Facility Personnel with no evidence of a TB Test and a Applicant Fingerprint Response.



Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8.

Exit interview was conducted With Marina Arshakyan, Appeals Rights discussed and a copy was given
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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 2


Document Has Been Signed on 11/08/2023 03:59 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
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: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2023
Section Cited
CCR
87405(a)

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Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator.....When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for
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The Licensee shall ensure that the facility has a qualified designated substitute who shall have the qualifications adequate to be responsible and accountable for management and administration of the facility. The Licensee will SUBMIT a WRITTEN PLAN OF ACTION that will be adhered to when
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management and administration of the facility as specified in this section. Per review of documents the Licensee designated Marine Arshakyan as staff in charge but she was not present at the facility until 1:20pm. The 2 staff present are not designated and it is unclear if they are qualified to administer the facility
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 the Administrator or the only designated responsible staff is not present at the facility for all shifts. Submit plan to LPA with completed LIC308 for designated staff working on each shift by 11/9/23
Type B
11/15/2023
Section Cited
CCR87412(a)(1-13(B)

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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: Employee's full name, social security, date of employment.....
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Licensee will ensure that all staff and volunteers have complete files containing all document noted under 87405(a)(1-13). Licensee will provide written evidence that Mariam Baghdoyan file has all the required information noted under Section
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This requirement was not met as Mariam Baghdoyan's file only contained: LIC508, LIC9182, LIC503 without evidence of TB test, Applicant Finger Print Response
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87412(a)(1-13) Personnel Records, including evidence of a TB test by 11/15/23
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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