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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 07/31/2025
Date Signed: 07/31/2025 04:38:06 PM

Document Has Been Signed on 07/31/2025 04:38 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/
DIRECTOR:		NADRIAN, ASMIKFACILITY TYPE:
740
ADDRESS:6215 BLUEBELL AVENUETELEPHONE:
(818) 903-6302
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 5DATE:
07/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:Arshalouis Manoukyan - AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 9:08AM. The LPA met with the Administrator Arshalouis Manoukyan, who arrived at 10:04AM, and explained the reason for the visit. Entrance interview conducted.

Beginning at 10:31AM, the LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and the facility is in compliance with Title 22 Regulations. The facility is a single-story residential home. The following was observed:

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The living room had an office area with locked cabinets that contained facility files and resident medications. Required postings were observed in the entryway hallway. The facility maintained a comfortable temperature throughout the visit.

KITCHEN: The LPA observed knives stored inaccessible in a locked cabinet. The lower cabinet contained four (4) pull out drawers, one (1) of which was broken off its hinges. The Administrator stated a maintenance man was scheduled to make repairs. Cleaning supplies were locked under the kitchen sink. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food. Food in the refrigerator and freezer were observed to be good quality.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2025
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 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 12
Document Has Been Signed on 07/31/2025 04:38 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/31/2025 at 03:37 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: 07/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 the cabinet in the garage was not secured and contained cleaning supplies and laundry detergent which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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The Administrator and Staff secured the cabinet during the visit. POC cleared.
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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 07/31/2025 04:38 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/31/2025 at 03:37 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: 07/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 twin mattress obstructed the side gate exit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2025
Plan of Correction
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The Licensee will discard of the mattress and send CCLD proof of the cleared passage by POC due date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 staff did not have a first aid/cpr training and the Licensee removed their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2025
Plan of Correction
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The Licensee will obtain the staff's first aid/cpr training and return the licensee's file and send copies to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 07/31/2025 04:38 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/31/2025 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: 07/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(12)
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in the infection control was not reviewed annually which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2025
Plan of Correction
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The Licensee will review, update, and sign the infection control plan and send it to CCLD by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 07/31/2025 04:38 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/31/2025 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: 07/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in the staff did not receive all required 40 hours of initial training and the licensee did not provide documentation to verify the annual trainings which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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The Licensee will review training regulations, create a plan to implement required hours and topics, and submit a statement of understanding to CCLD by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 07/31/2025 04:38 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/31/2025 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: 07/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 5 out of 5 residents did not have current centrally stored records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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The Licensee will submit updated centrally stored medication and destruction records for 5 residents and provide the records to CCLD by POC due date.
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 resident did not have records of their PRN administration which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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The Licensee will create and maintain a log for all residents who are prescribed PRN medications and send CCLD proof by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 07/31/2025 04:38 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/31/2025 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: 07/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 resident did not have completed forms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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The Licensee will review and complete the forms with the resident and send CCLD proof by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview, and record review, the licensee did not comply with the section cited above in the facility did not conduct quarterly drills and were not able to provide documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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The Licensee will review regulations, create a schedule to conduct emergency drills, and conduct them as scheduled. The Licensee will send CCLD the schedule and statement of understanding by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 07/31/2025 04:38 PM - It Cannot Be Edited


Created By: Quoc Huynh On 07/31/2025 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: 07/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in the licensee did not review/update their emergency disaster plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2025
Plan of Correction
1
2
3
4
The Licensee will review, update, and sign the emergency disaster plan and send it to CCLD by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Quoc Huynh
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2025


LIC809 (FAS) - (06/04)
Page: 9 of 12
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
VISIT DATE: 07/31/2025
NARRATIVE
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GARAGE: The garage entrance was attached to the kitchen. It contained general storage, non-perishables, emergency food and water, and laundry machines. The laundry machines were in good condition and operable. Next to the machines, was an unlocked cabinet that contained cleaning supplied and laundry detergent. Additionally, the cabinet was leaning to the left and observed to need repairs. The Administrator stated the maintenance man was made aware of the situation.

BEDROOMS/RESTROOMS: There were four (4) total bedrooms. Bedrooms #4 had a direct exit to the outside and approved for one (1) bedridden resident. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens were stored in the garage. There were three (3) total restrooms in the facility: two (2) private restrooms attached to Bedroom #1 and Bedroom #4 and one (1) shared resident restroom located in the hallway. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap and paper products. Hot water was tested in the resident restrooms and measured between 107.6 degrees F and 110.3 degrees F, which was within range.

OUTDOOR AREA: The surrounding rear yard had one (1) shaded patio area equipped with furniture in good condition for resident and visitor use. The LPA observed the back left fence to be in disrepair. Several panels were missing from the fence, and two (2) panels were observed leaning off and on the ground. The Administrator stated a gardener visits the facility once a week, and the fence is their responsibility. There were two side gates with a self-latching mechanism. One side gate was not accessible to open and the LPA observed a twin mattress obstructing the path to the front yard. The Administrator stated the mattress would be picked up today, 07/31/2025. The second side gate was designated as the emergency exit and led to the front yard.

RECORDS: Record review began at 10:55AM. Resident records were reviewed for, but not limited to care plans, physician's report, admission agreement, and consent forms. Resident #1’s (R1) Consent Forms and Emergency Identification form were not complete at this time.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC809 (FAS) - (06/04)
Page: 10 of 12
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
VISIT DATE: 07/31/2025
NARRATIVE
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Additionally, the LPA observed the Administrator make copies of Resident #2’s (R2) admission agreement, utilized white out, signed R1’s initials, and placed the documents into R1’s file. When the LPA addressed it, the Administrator stated the forms had been misplaced and the LPA stated their observations to which the Administrator admitted they signed R1’s initials because their POA was unable to complete the documents. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Staff #1 (S1) did not have their first aid/CPR training on file. The Licensee did not have their documents in their file, with the exception if their Personnel Record. The Administrator stated the Licensee took their documents and was not aware of the action. Staff training requirements were not met as the Employee Initial Orientation did not include 2 hours of Policies and Procedures regarding medications and 10 hours of medication training (6 hours of hands-on training of which 2 hours are shadowing and 4 hours of other instruction in the first 2 weeks). Additionally, Staff annual training documents were observed between 01/2025 and 03/2025, with no additional training records for verification.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and were not reviewed annually as required. Emergency disaster drills were not conducted quarterly, with the last documented drill on 01/11/2025. Smoke and carbon monoxide detectors were tested at 10:53AM and were operational.

MEDICATIONS: Medication review began at 2:21PM. Medications were centrally stored and kept inaccessible. Medications were observed for three (3) residents. Medications were not labeled and were not properly documented on the centrally stored medications and destruction record (CSMDR). Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5) did not have current CSMDRs.

Report Continued on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC809 (FAS) - (06/04)
Page: 11 of 12
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
VISIT DATE: 07/31/2025
NARRATIVE
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R3 had three (3) medication bottles: Fluoxetine filled on 05/16/2025, Olanzapine filled on 07/18/2025, and an additional unlabeled Olanzapine bottle. R3’s CSMDR showed Fluoxetine filled on 05/06/2025. R4 had eleven (11) medication bubble packs filled on 07/16/2025 and three (3) medications filled on 07/23/2025. Additionally, R4 was prescribed two (2) PRN (as needed) medications, and the facility did not document the administration of each dose. R5 had two (2) medications filled on 07/07/2025 and five (5) medications filled on 07/16/2025. R4 and R5’s CSMDR showed medications filled throughout the month of June 2025.

Three (3) Staff and three (3) residents were interviewed.

Pursuant to Title 22 CA Code of Regulations and/or Health and Safety Code, the following deficiencies were cited (Refer to LIC 809-D).

The Administrator was unavailable and the LPA reviewed the report via telephone call . The Administrator designated Staff Mariam Baghdayan to sign the report.

Exit interview conducted. A copy of the Appeal Rights and report was reviewed and provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC809 (FAS) - (06/04)
Page: 12 of 12