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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 05/18/2022
Date Signed: 05/18/2022 04:25:20 PM

Document Has Been Signed on 05/18/2022 04:25 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: 4DATE:
05/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marine ArshakyanTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management- Deficiencies visit at the facility today due to deficiencies observed during an initial complaint visit for complaint control # 29-AS-20220512132643.

At 9:13 a.m., the LPA observed one (1) bed with a mattress, and was completed with full linens in the facility’s Dining room. The Administrator confirmed that facility staff have been using the bed to rest at night. The LPA advised the administrator the facility shall provide comfortable living accommodations and privacy for the residents, and staff who may reside in the facility. The administrator acknowledged, and stated that the bed be removed from the facility dining room.

At 9:15 a.m., the Administrator advised LPA Walker that one (1) facility resident was hospitalized on 05/09/22. Record review revealed that the facility failed to submit a written report to Licensing regarding Resident #1 (R1) being hospitalized. The LPA advised the administrator that a written report shall be submitted to the licensing agency within seven (7) days of the occurrence of any incident which threatens the welfare, safety or health of any resident. The Administrator acknowledged, and stated they will ensure an incident report is submitted for R1 to CCLD by 5/19/22.

During today’s visit, the LPA conducted a physical plant tour along with Administrator Asmik Nadrian. At 9:39 a.m., the LPA observed Resident #2 (R2) 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).
Continue on LIC809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: HM SWEET HOME
FACILITY NUMBER: 197609604
VISIT DATE: 05/18/2022
NARRATIVE
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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.

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. A copy of the report and appeal rights were reviewed and provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/18/2022 04:25 PM - It Cannot Be Edited


Created By: Salia Walker On 05/18/2022 at 11:46 AM
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: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
87211(a)(1)(D)

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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events...: (D) Any incident which threatens the welfare, safety or health of any resident ....
This requirement is not met as evidenced by:
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The Licensee agreed to do the following:
1. Submit incident report for R1's hospitalization to CCLD.
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Based on record review and interview with the administrator, the licensee failed to comply with the section cited above as the facility failed to submit R1 being Hospitalized as required, which poses a potential health and safety risk to residents in care.
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Type B
05/20/2022
Section Cited
CCR87307(a)

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87307(a)Personal Accommodations and Services (a)Living accommodations and grounds.. facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff..who may reside in the facility..
This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:
1. Remove the bed from the facility's dinning room, and submit proof to CCLD.
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Based on LPA observation and interview with the administrator, the licensee did not comply with the section cited above, as there was one (1) bed with a mattress, and was completed with full linens in the facility’s Dining room, which poses a potential health, safety, and personal rights 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: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/18/2022 04:25 PM - It Cannot Be Edited


Created By: Salia Walker On 05/18/2022 at 11:58 AM
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: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2022
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 R2 into bedroom #4, which is the only room fire cleared for bedridden residents.
2.Submit proof to CCLD by 05/19/22.

Civil penalty assessed for zero-tolerance violation.
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Based on LPA observation, and interview with the Administrator, the licensee did not comply with the section cited above, as R2 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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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: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022


LIC809 (FAS) - (06/04)
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