Community Care Licensing

Document Has Been Signed on 08/26/2024 06:11 PM - It Cannot Be Edited

FACILITY NAME:	HM SWEET HOME		FACILITY NUMBER:	197609604
ADMINISTRATOR/ DIRECTOR:	NADRIAN, ASMIK		FACILITY TYPE:	740
ADDRESS:	6215 BLUEBELL AVENUE		TELEPHONE:	(818) 903-6302
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 6	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:53 AM
MET WITH:	Asmik Nadrian, Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:15 PM

SUPERVISORS NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024

Link to Parent Document Below:

FACILITY NAME: HM SWEET HOME	FACILITY NUMBER: 197609604
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above per review of the facility's commercial general insurance policy for coverage period 12/21/23-12/21/24, the policy limits are $1,000,000 per occurrence and a total annual aggregate of $2,000,000 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/03/2024
	Plan of Correction
1 2 3 4	Licensee will contact their insurance company to obtain the required insurance coverage and limits of $1,000.000 per occurrence and for a annual total aggregate of $3,000, 000

Type B

Section Cited

HSC

1569.618(c)(3)

(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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 4 staff files reviewed, did not contain evidence that Asmik Nadrian, Administrator, Mariam Baghdoyan, Caregiver and Emilya Hovsepyan , Cargiver have current first aid/CPR training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	The Licensee will submit a written plan of action as to how the facility will come into complaince with the section being cited and how the facility will ensure that there is staff who have received first aid training and CPR training on the premises at all times. Submit the written plan of action or submit evidence that the staff have received current training by 8/27/24.

SUPERVISOR'S NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024

Link to Parent Document Below:

FACILITY NAME: HM SWEET HOME	FACILITY NUMBER: 197609604
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

Type B

Section Cited

HSC

1569.319(a)

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above per information provided, the facility has computers but it is provided if the residents request them, the facility has not provided a dedicated computer for resident use which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/03/2024
	Plan of Correction
1 2 3 4	Licensee will ensure that a internet access device, such as a computer, smart phone, tablet or other device that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions is provided and dedicated for resident use by 9/3/24

Type B

Section Cited

HSC

1569.319(b)(2)

(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use: (2) The device shall be made available to residents in a manner that permits shared access among all residents in the facility during reasonable hours. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews, the licensee did not comply with the section cited above, the licensee does not have a computer policy in place to ensure that the device will be made available to the resident in a manner that permits shared access among the residents in the facility during reasonable hours which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/03/2024
	Plan of Correction
1 2 3 4	LIcensee will implement a written policy that will be provided to the residents so they are made aware of the facility's policy on having access to the device during reasonable hours by 9/3/24

SUPERVISOR'S NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024

Link to Parent Document Below:

FACILITY NAME: HM SWEET HOME	FACILITY NUMBER: 197609604
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

Type B

Section Cited

CCR

87458(a)

(a) 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. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 6 files reviewed, a medical assessement signed by a physician, made within the last year was not requested for Resident #4 prior to acceptance as a resident, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/03/2024
	Plan of Correction
1 2 3 4	Licensee will ensure that a medical assessment signed by a physician, made within the year is obtained for all residents prior to acceptance as a resident and maintained in the resident's file. Submit evidence that the medical assessment has been obtained by 6/3/24.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024