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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 02/27/2024
Date Signed: 02/27/2024 03:26:45 PM


Document Has Been Signed on 02/27/2024 03:26 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: 3DATE:
02/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Asmik Nadrian, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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During the complaint investigation of complaint # 29-AS-20231107095933, the following deficiencies were observed:
On 01/30/2024, at approximately 9:30am, Investigator Spindola interviewed Nasmik Nadrian, facility administrator. The administrator admitted that Witness #1 (W1) was not a facility staff but was present at the facility. The administrator denied that W1 co-owned the facility. The administrator stated W1 was a long-time friend and sometimes visits the facility. It was reported by other witnesses that W1 had been present in the facility on more than one occasion to assist with paperwork. The Department determined W1 was not cleared or associated to the facility.

On 10/07/2023, Resident #2 (R2) called 911 after Resident #1 (R1) complained of strong pain to their stomach. R2 called 911 to get an ambulance to transport R1 to the hospital because R2’s English was better than the caregiver. During the initial complaint visit conducted on 11/08/2023, LPA Christine Yee documented that no interviews were conducted as staff present had no information or spoke very limited English. They also stated that they are just caregivers.

During the 11/08/2023 complaint visit file review, it was noted that Resident #1 (R1) was hospitalized on 10/07/2023 and 10/21/2023. It was also noted that Resident #6 (R6) was deceased. There were no Special Incident Reports (SIRs) or death report submitted to Community Care Licensing (CCL).

Citations issued, $500 Immediate Civil Penalty issued, exit interview, appeal rights given.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
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 3


Document Has Been Signed on 02/27/2024 03:26 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: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2024
Section Cited
CCR
87355(e)(1)

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87355(e)(1) Criminal Record Clearance All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the
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Licensee will read and review Title 22 Regulation 87355 Criminal Record Clearance and submit memo of understanding to CCL. Submit to CCL by 2/28/24
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Department. This requirement is not met as evidenced by: Based on record review and interviews, the licensee allowed W1 to be present at the facility with a Criminal Record Clearance, which posed an immediate health and safety risk to residents in care.
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Type B
02/28/2024
Section Cited
CCR87211

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87211(a)(1)(A)(B) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)(1) A written report shall be submitted to the licensing agency and to the person responsible for
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Licensee will read and review Title 22 87211 Reporting Requirements and submit plan to report incidents and deaths timely. Submit to CCL by 2/28/24.
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 the resident within seven days of the occurrence… (A) Death of any resident from any cause regardless of where the death occurred… (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. the licensee failed to submit Special Incident Reports (SIRs) for R1’s 10/07/2023 and 10/21/2023 hospital admissions, and R6’s death, which posed 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.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3


Document Has Been Signed on 02/27/2024 03:26 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: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2024
Section Cited
CCR
87468.2(a)(4)

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Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, …shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered
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Licensee will submit plan how you will ensure staff are able to communicate with residents, emergency personnel, and the Department. Submit to CCL by 3/3/24
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by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidenced by: staff spoke minimal English and were not competent in communicating with LPA, residents, or emergency personnel, which posed 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.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine YeeTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3