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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 01/24/2022
Date Signed: 01/25/2022 07:51:13 AM

Document Has Been Signed on 01/25/2022 07:51 AM - 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:
01/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Anahit HovhannisyanTIME COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control #29-AS-20211221131518. The LPA was greeted by staff. Staff contacted the administrator. The LPA spoke with administrator and explained the reason for the visit.

While conducting file residents’ review, the LPA found that the licensee failed to submit a Special Incident Report (SIR) within seven days, as specified by regulations for one of the residents.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted with staff Anahit Hovhannisyan. Today's report and appeal rights were reviewed, and issued. Citations were cleared during today’s inspection. A copy of the report was issued via email
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2022
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 01/25/2022 07:51 AM - It Cannot Be Edited


Created By: Sandra Urena On 01/24/2022 at 01:24 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: 01/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2022
Section Cited
CCR
87211(a)(1)(A)

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87211-Reporting Requirements-(a)Each licensee... (1) A written report shall be submitted to the licensing agency…for the resident within seven days of the occurrence…(A)Death of any resident from any cause regardless of where the death occurred...This requirement is not met as evidence by:
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Licensee submitted Death LIC 624A on 1/24/2022. POC is cleared on 1/24/2022.
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Based on observation, interviews and record review, Licensee did not ensure to submit a death report to the RO within the seven days per regulations, which poses a health and safety, personal risk to persons 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:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2022


LIC809 (FAS) - (06/04)
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