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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609604
Report Date: 07/31/2025
Date Signed: 07/31/2025 04:50:02 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
02/11/2025 and conducted by Evaluator Quoc Huynh
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20250211151153
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:
07/31/2025
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Arshalouis Manoukyan - AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained multiple pressure injuries due to staff neglect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. The LPA arrived at 9:08AM and met with Administrator Arshalouis Manoukyan, who arrived at 10:04AM, and explained the reason for the visit. Entrance interview conducted.

At 10:31AM, the LPA and Administrator toured the physical plant areas to ensure there were no health and safety hazards. No immediate concerns were observed.

On 02/11/2025, the Department received a complaint regarding an allegation for Neglect/Lack of Care and Supervision. Former Resident #1 (R1) sustained multiple pressure injuries while in care due to staff neglect. The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Veronica Padilla.

Report Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
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 7
Control Number 29-AS-20250211151153
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: 07/31/2025
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
26
27
28
29
30
31
32
On 02/12/2025, from 11:54am to 6:45pm, LPA Christine Yee conducted an unannounced complaint visit and was let into the home by Mariam Baghdoyan, caregiver. Licensee Asmik Nadrian and Administrator Elena Kordonskiy were not available to participate in the visit. LPA Yee explained the reason for the visit and conducted a health and safety check during the visit. The visit was conducted entirely with Mariam Baghdoyan, caregiver. Emilya Hovsepyan, caregiver was also present during the visit. LPA toured the home and visually observed the residents in care beginning at 2:59pm. During the tour, inside and outside, no obvious concerns were observed with the physical plant and the residents. During the visit, facility records that were available were reviewed and copies obtained. The LPA determined further investigation was needed prior to issuing findings.

On 02/24/2025, at approximately 11:55am, Investigator Padilla conducted interviews with R1’s resident representative; on 03/13/2025, from approximately 12:00pm to 12:15pm, with residents; on 03/19/2025, at approximately 11:15am, with R1’s resident representative; on 05/20/2025, from approximately 10:20am to 11:45am, with Administrator and staff; on 06/09/2025, at approximately 1:10pm, with R1; and on 06/16/2025, at approximately 2:00pm, with Kaiser Hospital social worker. Contact was made with Los Angeles Police Department (LAPD) who confirmed there were no active cases regarding the complaint allegation. The Wise and Healthy Aging Ombudsman office was also contacted who were unable to confirm or deny the matter as R1 had not provided prior consent for discussion. In addition, Investigator Padilla reviewed Sunray Healthcare Center discharge instructions, Kaiser Hospital medical records, Neogen Care Home Health records, Sherman Oaks Hospital records, photos, and facility file documents related to the investigation.

According to the discharge instructions from Sunray Healthcare Center, on 12/31/2024, R1 was discharged from Sunray Healthcare Center with the following diagnoses: type II diabetes, hypertension, hyperlipidemia, Parkinson’s disease without dyskinesia, history of falling, spinal stenosis in the cervical region, myelopathy, benign prostatic hyperplasia with lower urinary tract symptoms, muscle contracture of the left arm, unspecified dementia of unspecified severity without behavioral disturbance, psychotic disturbance with mood disturbance and anxiety, hereditary and idiopathic neuropathy, major depressive disorder, sleepwalking, repeated falls, other abnormalities of gait and mobility, and muscle weakness.

Report Continued on LIC 9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20250211151153
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: 07/31/2025
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
26
27
28
29
30
31
32
It was also noted that R1 had occasional incontinence and did not require a catheter. In addition, the records did not indicate any skin issues present at the time of discharge.

The review of the Neogen Care Home Health records revealed on 12/30/2024 the Registered Nurse (RN) completed an assessment of R1 for physical and occupational therapy services. It was noted that R1 "did not have any unhealed pressure ulcers or injuries at stage two or higher, nor any designated as unstageable." The records documented that R1 relies on caregivers for activities of daily living (ADLs) and requires complete assistance with both bed mobility and transferring from a supine position to a standing position. The records also indicated that due to limited mobility, R1 was at risk of developing pressure sores, joint contractures, and muscle atrophy.

On 01/01/2025, R1 was admitted to the HM Sweet Home facility. A review of the preplacement appraisal and resident appraisal noted that R1 was a high fall risk, had weakness in the thighs and left side, non-ambulatory, unable to walk without physical assistance and requires the use of a walker or wheelchair. Bed status was noted as in bed all or most of the time, needs assistance with transferring in and out of bed, dressing, bathing, and personal hygiene. The documents also noted R1 had incontinence but did not require a catheter.

A review of the Sherman Oaks Hospital medical records documented that on 01/11/2025, R1 was brought to the Emergency Room (ER) for the chief complaint of bilateral leg pain. No redness or swelling noted, x-rays revealed no evidence of fracture. R1 was released back to the facility.

On 01/13/2025, R1 was sent to Kaiser Hospital ER due to confusion and increased urinary frequency. R1 was diagnosed with sepsis without acute organ dysfunction, diabetes mellitus 2 with hyperglycemia, Parkinsonism, spinal stenosis of cervical spine with myelopathy, major neurocognitive disorder, and acute urinary tract infection (UTI). The ER critical care notes document R1 was in critical condition and required constant monitoring.

Report Continued on LIC 9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20250211151153
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: 07/31/2025
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
26
27
28
29
30
31
32
A skin assessment noted wounds/lesions on R1’s left lateral thoracic area, right medial foot, moisture associated skin damage on the sacral area, wounds on both knees and skin lesion on the left upper arm. Photos were taken of the multiple wounds. On 01/15/2025, R1 was seen by the Kaiser wound care RN who diagnosed R1 with four “CAPI (Community Acquired Pressure Injuries) wounds” which means that R1 did not acquire the pressure injuries at the hospital.

Information obtained through interviews revealed the Administrator, Elena Kordonskiy, Staff #1 (S1) and Staff #2 (S2) acknowledged seeing and attempting to treat R1’s wounds but noted that R1 should have been in a facility that could provide a higher level of care. Both S1 and S2, stated that R1 was too heavy to be moved and remained in bed all day.
Based on the records reviewed and interviews conducted, the Department found sufficient evidence to prove that the facility was responsible for the neglect leading to R1 sustaining multiple pressure injuries. Therefore, the allegation is deemed Substantiated at this time.

A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22 California Code of Regulations and/or Health and Safety Code, the following deficiency is cited (refer to LIC 9099-D).

The Administrator was unavailable and the LPA reviewed the report via telephone call . The Administrator designated Staff Mariam Baghdayan to sign the report.

Exit interview conducted. A copy of the Appeal Rights and report was reviewed and provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20250211151153
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: 07/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2025
Section Cited
HSC
1569.312(a)
1
2
3
4
5
6
7
Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The Licensee will update staff training on resident care and transfers, evaulate staff and residents, and submit a statement of understanding to CCLD by POC due date.
8
9
10
11
12
13
14
Based on interviews and records review, the licensee did not comply with the section cited above. The facility staff's neglect led to R1 sustaining multiple pressure injuries, which posed an immediate 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
02/11/2025 and conducted by Evaluator Quoc Huynh
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20250211151153

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:
07/31/2025
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Arshalouis Manoukyan - AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not treat resident with dignity or respect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegation. LPA arrived at 9:08AM and met with Administrator Arshalouis Manoukyan, who arrived at 10:04AM, and explained the reason for the visit. Entrance interview conducted.

Beginning at 9:41AM, the LPA interviewed three (3) residents. At 10:31AM, the LPA and Administrator toured the physical plant areas to ensure there were no health and safety hazards. No immediate concerns were observed. Between 10:12AM and 12:30PM, the LPA interviewed three (3) staff and reviewed files. The following was determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20250211151153
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: 07/31/2025
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
26
27
28
29
30
31
32
Allegation: Staff did not treat resident with dignity or respect

It was reported that facility staff do not treat residents with dignity or respect and were observed to yell and berate the residents. Interview with Resident #1 (R1) revealed they do not get along with staff and one (1) staff is known to yell at residents. R1 reported they are sometimes nice however they will quickly change and are not respectful. R1 experienced the staff yelling at them for not accepting a shower when the staff offered it. Resident #2 (R2) and Resident #3 (R3) stated staff are nice to them and have not experienced staff yelling at them or observed them yelling at others. R3 added that they believe staff can come off as aggressive due to the language barrier and their culture; however, R3 has not observed staff handle residents in an aggressive manner. Interview with three (3) staff revealed all staff are very patient and understanding of residents’ conditions and treat them with respect. The Administrator stated HM Sweet Home’s company provided staff monthly training on resident care, rights, and treatment. Additionally, resident record review revealed R2 had a hearing impairment and staff reported R2 does not always wear their hearing aids.

Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED at this time.

The Administrator was unavailable and the LPA reviewed the report via telephone call . The Administrator designated Staff Mariam Baghdayan to sign the report.

No deficiency cited for the above allegation. Exit interview conducted. A copy of today’s report was reviewed and provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7