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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609604
Report Date: 01/06/2025
Date Signed: 01/06/2025 02:26:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/02/2025 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20250102112138
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:
01/06/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elena Kordonskiy TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff overmedicated a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Emily Peraldi and Angela Barutyan conducted an unannounced initial complaint visit to this facility. At 9:30 a.m., the LPAs met with staff and explained the reason for the visit. At 10:15 a.m., the Administrator, Elena Kordonskiy arrived at the facility.

Between 9:40 a.m. and 10:15 a.m., the LPAs conducted interviews with the Administrator, two (2) staff and four (4) residents. At 10:02 a.m., the LPAs, along with staff conducted a physical plant tour. At 10:20 a.m., the LPA requested and obtained copies of pertinent documents. Starting at 10:41 a.m., the LPAs conducted a review of medication and medication documentation with Administrator for four (4) residents.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 29-AS-20250102112138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/06/2025
NARRATIVE
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Regarding the allegation: Staff overmedicated a resident in care. During today’s visit, between 9:40 a.m. and 10:15 a.m., the LPAs conducted a review of medication and medication documentation with Administrator for four (4) residents and observed the following: Resident #1 (R1’s) Methotrexate Sodium 2.5 MG quantity (qty): 4 (Take 1 tablet by mouth every Wednesday for rheumatoid arthritis) was started on 12/28/2024 and had 1 tablet remaining, however, there should be a total of 3 tablets remaining instead. R1’s Melatonin 5 MG TABS qty: 30 was started on 12/28/2024 and had 12 tablets remaining, however there should be a total of 21 tablets remaining instead. Resident #2’s (R2’s) Lisinopril 20 MG Tab qty: 14 was started on 01/01/2025 and had 7 tablets remaining, however, there should be a total of 8 tablets remaining instead. Resident #3’s (R3’s) Ferrous Gluconate 324 MG Tab qty: 30 was started on 12/11/2024 and had 9 tablets remaining, however, there should be a total of 3 tablets remaining instead. R3’s Pantoprazole DR 40MG Tab qty: 30 was started on 12/11/2024 and had 9 tablets remaining, however, there should be a total of 3 tablets remaining instead. Based on observation, record review, and medication review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20250102112138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2025
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Within 24 hours, the Administrator will notify the LPA when medication training will be completed. Administrator stated that medication audit will be conducted and training for all staff. The Administrator stated she will submit documentation to CCL by 1/31/2024.
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Based on record review and observations, the licensee did not comply with the section cited above, as the facility staff did not properly assist with R1’s, R2’s, and R3’s self-administered medications per physician’s order which poses an immediate health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC9099 (FAS) - (06/04)
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