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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 07/21/2022
Date Signed: 07/21/2022 04:54:25 PM

Document Has Been Signed on 07/21/2022 04:54 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
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: 6DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Marine ArshakyanTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. Upon arrival, the LPA met with Designee Marine Arshakyan, and explained the reason for the visit.

At 12:45 p.m., the LPA observed the Los Angeles Fire Department (LAFD) at the facility transporting Resident #1 (R1) to the hospital. The LPA inquired with Designee Marine Arshakyan the reason for the ambulance being called. The Designee advised that the resident was new at the facility, and had issues with their catheter. The LPA asked the Designee if R1 is receiving Hospice or Home Health services, and the Designee stated “no.” At 1:03 p.m., the LPA contacted Administrator Asmik Nadrian via telephone to inquire if R1 is receiving Hospice or Home Health services; the Administrator stated, “no Hospice or Home Health.” The LPA advised the Administrator that under Title 22 Regulation 87623 (a) The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances: (A) Irrigation shall only be performed by an appropriately skilled professional in accordance with the physician's orders. At 1:12 p.m., the LPA observed Room #4 had two (2) residents residing in the bedroom. The LPA asked Resident #2 (R2) if they were residing in the room with Resident #3 (R3) as a roommate. R2 confirmed that the facility staff relocated R2 to room #4. The facility currently has the room numbers on the resident bedroom doors differing from the Facility Sketch, and room #4 at this time is displaying a #3 not in accordance with the Fire clearance nor submitted Facility Sketch. The LPA advised the Designee that the facility has an approved Fire Clearance for five (5) non-ambulatory residents total in rooms 1 (shared), 2 (shared), and 3 (shared); and, one (1) bedridden resident only in room #4 (private). The LPA also advised the Designee that the facility is in violation of Title 22 Regulation section 87203 Fire Safety, as the facility failed to maintain in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
Continue on LIC809C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: 07/21/2022
NARRATIVE
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The LPA toured the physical plant areas inside and outside, with Designee Marine Arshakyan at 1:40 p.m., to ensure there are no health and safety hazards. BEDROOMS: The LPA observed the resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: Resident restrooms are in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap, paper products, and hand-washing signs in each restroom. From 1:51 p.m. until 2:00 p.m., hot water temperatures measured between 124.2 and 126.9 degrees Fahrenheit in the common and private restroom(s). At 1:54 p.m. and 2:00 p.m., the LPA observed two (2) out of three restrooms not clean or sanitary. The LPA advised the Designee, and the Designee stated the facility “cleans daily.” On 06/22/22, the facility was previously cited for Title 22 Regulation section 87303(a) Maintenance and Operation. Civil penalties are being assessed, today 07/21/22, for a repeat violation. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 122.1 degrees Fahrenheit at 1:47 p.m. The LPA advised the Designee that all the temperature of hot water used by residents are to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). The Designee acknowledged. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed required postings in the hallway. At 1:29 p.m., one (1) fire extinguisher was observed to be fully charged; however the purchased date on the receipt displays 06/05/2018. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The garage contains additional nonperishable and perishable food items; and the facility laundry room is located in the garage. The garage is attached to the facility. INFECTION CONTROL: During today’s visit, the LPA spoke with the Designee regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is insufficient at this time. The Infection Control plan has not yet been submitted, and the Administrator will submit to CCL. This facility has records of staff and resident vaccinations. The facility can designate a single-person room to isolate persons if there is a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies, and procedures as it pertains to infection control.
Continue on LIC809C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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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: 07/21/2022
NARRATIVE
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The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Civil Penalties assessed for repeat violations. Failure to correct the deficiencies may result in civil penalties. 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: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 07/21/2022 04:54 PM - It Cannot Be Edited


Created By: Salia Walker On 07/21/2022 at 03:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HM SWEET HOME
FACILITY NUMBER: 197609604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee failed to ensure hot water temperature measured within 105 to 120 degrees F in resident rooms which poses an immediate health, and safety risk to residents in care.
POC Due Date: 07/25/2022
Plan of Correction
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The Licensee has agreed to do the following:
1. Submit proof by photos of tempurature adjustment.
2. Submit a hot water temperature log for five (5) days to maintain water temperature between 105 - 120 degrees F.
Type A
Section Cited
CCR
87203
87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as R3 is residing in room #4 which is fire cleared for one (1) bedridden resident only, and not a shared room; additionally, one (1) fire extinguisher was noted with a purchased date on 06/05/2018, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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The Licensee has agreed to do the following:
1. Submit photo of Room #4 retaining R3 in accordance to the approved Fire Clearance.
2. Submit proof of serviced/ newly purchased fire extinguisher to CCL by 7/29/2022.
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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 07/21/2022 04:54 PM - It Cannot Be Edited


Created By: Salia Walker On 07/21/2022 at 03:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HM SWEET HOME
FACILITY NUMBER: 197609604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation, the licensee did not comply with the section cited above as two (2) out of three (3) restrooms were not clean or sanitary, which poses a potential health and safety risk to residents in care.
POC Due Date: 07/25/2022
Plan of Correction
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The Licensee has agreed to do the following:
1.Submit photos of restroom toilets, and sinks cleaned and sanitary to CCL by 7/25/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 07/21/2022 04:54 PM - It Cannot Be Edited


Created By: Salia Walker On 07/21/2022 at 04:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HM SWEET HOME
FACILITY NUMBER: 197609604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87623(a)(A)
87623(a)(A) Indwelling Urinary Catheter (a)The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances: (A) Irrigation shall only be performed by an appropriately skilled professional in accordance with the physician's orders.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the licensee did not comply with the section cited above as R1 was retained
by the facility requiring the use of an indwelling catheter, and irrigation was not performed by an appropriately skilled
professional in accordance with the physician's orders, which poses an immediate potential health, safety or personal
rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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The Licensee has agreed to do the following:
1. Review section 87623 of the California Title 22 Regulation, and submit a statement of understanding to CCL by 07/25/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


LIC809 (FAS) - (06/04)
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