<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 12/27/2023
Date Signed: 12/28/2023 08:17:55 AM


Document Has Been Signed on 12/28/2023 08:17 AM - 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: 6DATE:
12/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Marine ArshakyanTIME COMPLETED:
11:47 AM
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 Analyst (LPA) Teresa Camara conducted an unannounced case management visit due to deficiencies noted during today's complaint investigation visit (complaint control number 29-AS-20231222121315). Upon arrival there were two caregivers present. Caregiver 1 (C1) called the administrator to come to the facility. Administrator Marine Arshakyan arrived at 10:32 a.m. LPA explained the reason for the visit.

During today's visit, LPA inspected the refrigerator at 9:53 a.m. LPA observed the refrigerator temperature was 40*F which is within the regulatory limit. However, the freezer temperature was 5*F which is above the regulatory temperature of 0*F. LPA observed the freezer drawer seal was loose and ice crystals were observed all over the food inside the freezer. This freezer is designed to be frost-free. In addition, the freezer drawer handle is broken.

Per California Code of Regulations (CCR), Title 22, see LIC 809-D for deficiencies cited. Exit interview conducted. A copy of the report was issued, along with appeal rights.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
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 12/28/2023 08:17 AM - 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: 12/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/05/2024
Section Cited
CCR
87555(b)(21)

1
2
3
4
5
6
7
87555 General Food Service Requirements. (b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C)... This regulation was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will either have the freezer repaired or replaced by 1/5/2024 and provide evidence of the repair or replacement to CCL.
8
9
10
11
12
13
14
Based on LPA's observations, the licensee did not comply with the section cited above, as the freezer temperature was 5*F and ice crystals had formed on the food inside, which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2