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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 01/14/2022
Date Signed: 01/14/2022 05:07:53 PM

Document Has Been Signed on 01/14/2022 05:07 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:
01/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Asmik Nadrian, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- Deficiencies inspection visit at the facility today due to deficiencies observed during a initial complaint visit, control #29-AS-20220113115003.

During today’s visit, the LPA attempted to interview resident #1 (R1) at 1:35 p.m. and once more at 4:15 p.m. Staff, and the administrator confirmed that R1 needs to be assisted with repositioning. A review of R1’s file revealed that R1 is paralyzed, bedbound, and required maximum assistance. R1 is currently residing in room #1 which is fire cleared for non-ambulatory only. The facility currently has the room numbers on the resident bedroom doors differing from the Facility Sketch, and room #1 at this time is displaying a #4 not in accordance with the Fire clearance nor submitted Facility Sketch. The LPA advised the administrator 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 Administrator that this is a fire clearance violation due to the facility’s acceptance and retention limitations, Title 22 Regulation section 87202 Fire Clearance; 87455(c)(4)(g) Acceptance and Retention Limitations; 87208 Plan of Operation and H&S CODE 1569.72. At 1:29 p.m., the LPA observed two holes on the wall in the private restroom of room #3. The LPA advised the administrator that the facility shall always be in good repairs, and inquired regarding fixtures. The administrator acknowledged, and stated she did not have knowledge of the two holes on the wall and will be repairing them. At 1:42 p.m., the LPA observed common restroom in hallway had a broken toilet seat. The administrator stated she will have the toilet seat replaced. The LPA advised the administrator that the broken toilet seat is not safe, and shall be in good repair at all times. The administrator agreed, and acknowledged.
The following deficiencies were observed (See LIC 809-D), and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Immediate Civil Penalty assessed for Fire Clearance Violation.
Exit interview conducted. Appeal rights discussed, and a copy of the report and appeal rights were provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2022
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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Document Has Been Signed on 01/14/2022 05:07 PM - It Cannot Be Edited


Created By: Salia Walker On 01/14/2022 at 03:27 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: 01/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2022
Section Cited
CCR
87202(a)(2)

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87202(a)(2) Fire Clearance (a)All facilities shall.. Prior to accepting or retaining any of the following types of persons.. the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance.. (2) Bedridden persons.
This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:
1. Move R1 into bedroom #4, as bedroom #4 is the only room fire cleared for bedridden residents. Complete by end of the day.

Civil penalty assessed for zero-tolerance violation.
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Based on Record review and LPAs observation, the licensee did not comply with the section cited above, as R1 is bedridden and currently residing in room #1 which does not have fire clearance for bedridden residents, which poses an immediate safety risk to resident in care.
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Type B
01/17/2022
Section Cited
CCR87303(a)

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87303(a) Maintenance and Operation: (a) 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:
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The Licensee has agreed to do the following:
1. Submit proof of repairs to the private restroom wall in room #3.
2. Submit proof of common restroom toilet seat replacement.
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Based on LPAs observation, the licensee did not comply with the section cited above, as there are two (2) holes on the wall in the private restroom of room #3; and the common restroom's toilet seat is in disrepairs, which poses a potential 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.
SUPERVISOR'S NAME:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2022


LIC809 (FAS) - (06/04)
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