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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 08/23/2023
Date Signed: 08/23/2023 05:30:55 PM

Document Has Been Signed on 08/23/2023 05:30 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 NORTH, 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:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marine Arshakyan, StaffTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was given entry into the home by Mariam Baghdoyan, Staff. LPA Yee contacted Asmik Nadrian via telephone and was informed that she would not be able to conduct the visit. Marine Arshakyan was contacted by the Administrator and she arrived at 10:08am to conduct the visit. Due to staff having difficulties locating files, Asmik Nadrian, Administrator arrived later to participate in the visit.

The home is a single storey family home consisting of a living room, dining room, a kitchen, 4 resident bedrooms, 3 bathrooms and a attached garage. The home is fire cleared for 5 non-ambulatory and 1 bedridden resident. Bedroom #4 is the room designated for bedridden use.

The following was observed on today's visit:
  • The dining room and living room have the appropriate furniture for 6 residents and was clean
  • The kitchen has a stove, refrigerator and a microwave were observed to be operational. Medications and knives are stored in a kitchen cabinet. At the time of the inspection, the cabinet was observed unlocked with magnet hanging on the refrigerator next to the cabinet. Cabinet was locked when pointed out.
  • insufficient perishable and non-perishable foods were observed in the kitchen and in the garage. Some of the canned foods such as soups and vegetables had expired.
  • Bedroom # 1 was observed furnished with the resident's own furniture consisting of a full size day bed, 2 dressers, night stand, chair and a built in closet. Located in the room is a bathroom equipped with a shower stall, toilet and sink. No grab bars or non-skid mats were observed. Water temperature was tested and read 137.5 degrees Fahrenheit.
  • Bedroom #2 has 2 hospital beds, 3 night stands, no lamps, no chairs, no dressers. Sufficient lighting was observed. Left bed was observed with a full bed rail for resident on hospice.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HM SWEET HOME
FACILITY NUMBER: 197609604
VISIT DATE: 08/23/2023
NARRATIVE
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  • Bedroom #3 has 2 hospital bed, 1 night stand, 1 lamp, no dresser, no chair. Sufficient lighting was observed. Closet door was broken and removed and replaced with a curtain. 1 hospital bed needs to be removed and closet door needs to be replaced. Facility linens stored in the room need to be relocated. Located in the room is a private bathroom with a shower stall, toilet and sink. No grab bars or non-skid mats were observed. Water temperature was tested and read 134.2 degrees Fahrenheit.
  • Bedroom #4 has 2 hospital beds, 2 night stands, no lamps, no chairs, no dressers. Sufficient lighting was observed. Back bed was observed with a full bed rail for resident on hospice.
  • The common bathroom located adjacent to bedroom #1 was observed with a shower stall. Located in the shower stall were a shower chair, grab bars and a non-skid mat. Water temperature was tested and read 136.1 degrees Fahrenheit.
  • The hardwired combination smoke and carbon-monoxide detectors were tested and were operational
  • The fire extinguisher located in the living room was purchased on 7/24/22 and has expired.
  • the garage is used for storage of the non-perishable foods, cleaning solutions, poisons and houses the washer and dryer.
  • Per information provided by staff, Staff #3 sleeps on the couch in the living room.
  • The Administrator has current Administrator certificate
  • Staff have current first aid training except for Marine Arkshayan
  • The backyard needs general cleaning. The dried vines and wood need to be discarded and the sliding glass door and gardening tools need to be store away. There was no shaded area or seating provided for outside activities. There were no bodies of water observed.


Due to time constraints, the following domains were completed on today's visit:
Infection Control, Operational Requirements and Physical Plant, Environmental Safety and Staffing. Any citations not addressed on today's visit will be addressed on a return visit.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was provided
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 08/23/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 08/23/2023 at 03:25 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: 08/23/2023

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 observation, the licensee did not comply with the section cited above in all the water temperatures taken in all 3 bathroom read outside of the range permitted by Title 22. The water termperature in Bedroom #1 read 137.5 degrees Fahrenheit, Bedroom #3 read 134.2 degrees Fahrenheit and the commom bathroom read 136.1 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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The Licensee will adjust the thermostat for the water heater to ensure that the hot water provided for resident use falls with Title 22 temperature range of 105 - 120 degrees Fahrenheit. Licensee will self-certify that the adjustment was made and that the water temperature is with Title 22 requirements by 8/24/23
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 the door to the garage was left unlocked during the tour of the facility beginning at 10:21am which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Licensee will provide a plan of action as to how she will ensure that all disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be made inaccessible to the residents in care.
The garage door was locked during the visit at the request LPA Yee.
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:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


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Document Has Been Signed on 08/23/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 08/23/2023 at 03:25 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: 08/23/2023

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 observatio], the licensee did not comply with the section cited above per tour of the backyard, the backyard was observed with dried flower vines, discarded sliding glass door, wood, gardening tools which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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The Licensee will perform general cleaning of the backyard and will discard the dried flower vines and wood along the side of the home, store away the gardening tools such as the spade and all items that is not being used. Provide POC by 8/30/23
Type B
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

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 per inspection of the 2 private bathrooms located in Bedroom #1 and Bedroom #3, both bathrooms are not equipped with grab bars for both residents use, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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The Licensee will have grab bars installed in the private bathrooms located in Bedroom #1 and Bedroom #3. Provide evidence that the grab bars have been provided by 8/30/23
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:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/23/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 08/23/2023 at 03:25 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: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

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 per tour of the 2 private bathrooms located in bedroom #1 and bedroom #3, both bathrooms were not observed with non-skid mats, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Lincensee will purchase non-skid mats and place them in the bathrooms located in bedroom #1 and bedroom #3 by 8/30/23
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above per information provided, Staff #1 does not have family close by and sometimes sleeps on the couch and stores her clothing in a portable closet in the garage, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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The Licensee will come up with a plan of action to ensure that the staff get the appropriate rest and time off between shifts and do not need to sleep on the couch. Provide plan of action by 8/30/23
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:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


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Document Has Been Signed on 08/23/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 08/23/2023 at 03:25 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: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(B)
Personal Accommodations and Services
(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.

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 per tour of the residents' room. Bedrooms #2, Bedroom #3 and Bedroom #4 do not have any dressers, chairs or chest of drawers for storage of personable belongings, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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The Licensee will provide the residents in Bedroom #2, Bedroom #3 and Bedroom #4 with a chair and a dresser that meets Title 22 requirement by 8/30/23. The chair may be a foldable chair.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above per review of all four staff files. Marine Arshakyan did not have evidence that she has received current first aid training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Licensee will ensure that Marine Arshakyan is scheduled only to work with another staff who has completed current first aid training until she is able to complete first aid training. Submit evidence of first aid training for Marine Arshakyan by 8/30/23
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:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 08/23/2023 05:30 PM - It Cannot Be Edited


Created By: Christine Yee On 08/23/2023 at 03:46 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: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises


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 per review of the food, there were insufficent persihables and non-perishable observed in the kitchen refrigerator and in the garage. Canned foods were also observed to be expired which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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Licensee will purchase more vegetables and fruits to meet the 2 day perishable requirement and review the canned food items to determine how many canned foods have expired and purchase the required 7 day non-perishable food requirement. Provide copy of the receipt by 8/24/23
Type A
Section Cited
CCR
87555(b)(9)
87555 General Food Service Requirements
(b) The following food service requirements shall apply (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation, the licensee did not comply with the section cited per review of the non-perishable foods stored on shelves in the garage, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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The Licensee will review all the canned foods to ensure that the canned foods have not expired. The Licensee agrees to discard all expired foods and replenish as necessary. Licensee will provide a plan of action that will be established to ensure that foods do not expire by 8/24/23.
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:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


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