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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 07/01/2022
Date Signed: 07/01/2022 10:05:01 AM

Document Has Been Signed on 07/01/2022 10:05 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
CCLD Regional Office, 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: 5DATE:
07/01/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Asmik Nadrian, AdministratorTIME COMPLETED:
10:00 AM
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Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- POC visit to the above facility to follow up on deficiencies issued during a Case Management-Deficiencies visit on 6/22/2022. The LPA met with Administrator Asmik Nadrian at 9:31 a.m., and explained the reason for the visit. Entrance interview conducted.

On 6/22/22, LPA Walker conducted an unannounced Case Management-Deficiencies visit at the facility, due to deficiencies observed during the investigation of complaint control # 29-AS-20210923141341. Upon entry the LPA was greeted by staff, as the Administrator advised the LPA, they were not able to be present during the visit.

At 9:30 a.m., the LPA conducted a File Review for seven (7) out of seven (7) resident files. The LPA contacted the Administrator via telephone to inquire about Resident #1 (R1) and Resident #2 (R2)’s resident files. The administrator confirmed that the facility does not have any files for R1 and R2. The LPA advised the Administrator that Title 22 requirements indicate that the licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. Record Review also revealed that Resident #3 (R3)’s file did not have a medical assessment/ physicians report in their file. The LPA advised the Administrator that prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year.

Continue on LIC809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HM SWEET HOME
FACILITY NUMBER: 197609604
VISIT DATE: 07/01/2022
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On 06/30/22 at 12:36 p.m., LPA Walker spoke to Administrator Asmik Nadrian. The Administrator stated that R1 was will not be ‘living at the facility.’ The Administrator emailed the LPA partial requested documents for R2’s resident file at 1:00 p.m. The Administrator also stated that R3’s medical assessment/ physicians report will be sent on 07/06/22. The LPA reminded the Administrator of the agreed Plans of Corrections, and advised that failure to correct deficiencies may result in civil penalties being assessed.

Civil penalties are being assessed today, 07/01/2022, for Failure to Correct deficiencies. Civil penalties will continue to accrue until proof of correction has been received by CCLD. Total amount of civil penalties assessed today is $2,100. Exit interview conducted. A copy of the report, and appeal rights were provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC809 (FAS) - (06/04)
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