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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 06/22/2022
Date Signed: 06/22/2022 04:31:59 PM

Document Has Been Signed on 06/22/2022 04:31 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:
06/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Anahit HovhannisyanTIME 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 the investigation of complaint control # 29-AS-20210923141341. Upon entry the LPA was greeted by staff, as the Administrator advised the LPA they were not able to be present during today’s visit.

At 9:15 a.m., the LPA observed Staff #1 (S1), and Staff #2 (S2) not wearing face coverings/ masks. The facility failed to protect the personal rights of residents in care to be able to receive safe and healthful accommodations, in that the facility staff failed to wear face coverings properly while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

At 9:26 a.m., during the physical plant tour, the LPA observed the facility’s kitchen refrigerator containing unsecured medication accessible to residents in care. At 9:27 a.m., the LPA advised the administrator via telephone medication shall be stored inaccessible to residents with dementia in a secured ‘Lock Box.’ The Administrator acknowledged, and stated a lock box will be purchased today 06/22/22.

At 9:29 a.m., during the physical plant tour, the LPA observed two (2) cabinets located under the facility kitchen sink in disrepairs; which contained accessible cleaning supplies to the residents in care. The LPA advised the Administrator of the cabinets not shutting properly.

Continue on LIC 809C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2022
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: 06/22/2022
NARRATIVE
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At 9:30 a.m., the LPA conducted a File Review for seven (7) out of seven (7) resident files. Upon requesting resident files for Resident #1 (R1), and Resident #2 (R2); S1 advised the LPA that “there are no files” for R1 or R2 due to the residents being recently admitted. The LPA contacted the Administrator via telephone to inquire about R1 and R2’s resident files. The administrator confirmed that the facility does not have any files for R1 and R2. The LPA asked the Administrator for R1 and R2’s first name, last name, and date of births. However, the Administrator only had knowledge of R1’s first name, and stated that R1’s family member only “asked if [the facility] can care for [R1] a couple of days.” The Administrator did not have information on R1’s last name, or date of birth. Additionally, the Administrator did not know R2’s first name, last name, or date of birth. The Administrator then stated that the facility has “seven days upon admitting a resident to the facility, to get the resident’s physicians report and files ready.” The LPA advised the Administrator that was incorrect, and Title 22 requirements indicate that 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. Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. Record Review also revealed that Resident #3 (R3)’s file did not medical assessment/ physicians report in their file. The LPA advised the Administrator that prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made
within the last year.

At 9:44 a.m., the LPA requested Resident #4 (R4), and Resident #5 (R5)’s resident files from S1. S1 advised there were no files in the facility for R4, and R5. The LPA contacted the Administrator via telephone once more to inquire where the resident files where for R4, and R5. The LPA advised the Administrator that original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. The administrator stated they “[kept] the copies, but it is not in the Facility;” and that the resident files were in their possession.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report, and appeal rights were provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/22/2022 04:31 PM - It Cannot Be Edited


Created By: Salia Walker On 06/22/2022 at 03:34 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: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2022
Section Cited
CCR
87468.1(a)(2)

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87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:
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The Licensee has agreed to the following:
1.Hold an in-service training with all staff, reviewing masking guidelines. Submit sign in sheet to CCL no later than 6/23/2022.
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Based on LPA’s observation, the licensee did not comply with the section cited above as S1 and S2 were observed not wearing face coverings/masks while providing care and supervision to residents in care, which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
06/23/2022
Section Cited
CCR87705(f)(2)

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87705(f)(2) Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication... cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
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The Licensee has agreed to the following:
1.Submit photo of purchased lock box, and secured/locked medication in the facility’s kitchen refrigerator.
2.Submit photo of locked/ secured cleaning supplies and disinfectants located in the cabinets under the kitchen sink.
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Based on LPA’s observation, the licensee did not comply with the section cited above as the facility contained unsecured medications, and cleaning supplies and disinfectants accessible to residents with dementia, which poses an immediate 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:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/22/2022 04:31 PM - It Cannot Be Edited


Created By: Salia Walker On 06/22/2022 at 03:38 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: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2022
Section Cited
CCR
87506(a)

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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:
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The Licensee has agreed to the following:
1.Submit copies of R1 and R2’s resident records to CCLD by 6/24/22.
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Base on the record review, the facility failed to ensure that a resident’s file for R1 and R2 were created/maintained prior to admission and available to the licensing agency staff, which poses an immediate health and safety, personal risk to persons in care.
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Type A
06/24/2022
Section Cited
CCR87457(c)

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87457(c) Pre-Admission Appraisal – General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and.. include an appraisal of his/her individual service needs...

This requirement is not met as evidenced by:
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The Licensee has agreed to the following:
1.Submit copies of R1 and R2’s Pre-Admission Appraisals/ Needs and Services Plans to CCLD by 6/24/22.
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Base on the record review, the facility failed to ensure that prior to admission a suitability for admission including an appraisal of R1 and R2’s needs were completed, which poses an immediate 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:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 06/22/2022 04:31 PM - It Cannot Be Edited


Created By: Salia Walker On 06/22/2022 at 03:44 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: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2022
Section Cited
CCR
87458(a)

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87458(a) Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year...
This requirement is not met as evidenced by:
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The Licensee has agreed to the following:
1.Submit copies of R1, R2, and R3’s Medical assessment/ Physicians reports to CCLD by 6/24/22.
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Base on the record review, the facility failed to obtain/keep on file a medical assessment/physicians report for R1, R2, and R3, which poses an immediate 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:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/22/2022 04:31 PM - It Cannot Be Edited


Created By: Salia Walker On 06/22/2022 at 03:51 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: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/29/2022
Section Cited
CCR
87303(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 made to the two (2) cabinets to CCL by 6/29/22.
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Based on LPAs observation, the licensee did not comply with the section cited above as two (2) cabinets located under the facility kitchen sink are in disrepairs, which poses a potential health and safety risk to residents in care.
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Type B
06/29/2022
Section Cited
CCR87506(e)

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87506(e) Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.

This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:
1.Submit copies of R4, and R5’s resident files to CCL by 6/29/22.
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Based on record review and interviews, the licensee did not comply with the section cited above as no resident records were retained for R4 and R5, 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: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2022


LIC809 (FAS) - (06/04)
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