Community Care Licensing

Document Has Been Signed on 01/16/2024 04:59 PM - It Cannot Be Edited

FACILITY NAME:	HM SWEET HOME		FACILITY NUMBER:	197609604
ADMINISTRATOR:	NADRIAN, ASMIK		FACILITY TYPE:	740
ADDRESS:	6215 BLUEBELL AVENUE		TELEPHONE:	(818) 903-6302
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY: 6		CENSUS: 5	DATE:	01/16/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	03:18 PM
MET WITH:	Marine Arshakyan, Staff		TIME COMPLETED:	05:05 PM

SUPERVISORS NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024

Link to Parent Document Below:

FACILITY NAME: HM SWEET HOME	FACILITY NUMBER: 197609604
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/16/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/23/2024 Section Cited CCR 87507(g)(1-3)(A)	1 2 3 4 5 6 7	(g) Admission agreements shall specify the following:(1) Basic services, as defined in Section 87101(b), to be made available.(2) Additional items and services which are available. (3)Payment provisions, including the following: obtain and maintain a license. (A) Rate for all basic services which the	1 2 3 4 5 6 7	Licensee will review all resident files to ensure that all Admission Agreements have been completed and signed by the resident or the designated representative. Licensee will FAX over a writtten and signed statement that all the admission agreements have been reviewed
	8 9 10 11 12 13 14	facility is required to provide in order to maintain a license. Per review facility files, Admission Agreements were observed to be missing signatures, rate for basic and optional services, acknowledgement of Personal Rights, Resident Council,,,,including Resident #5	8 9 10 11 12 13 14	and completed as required and a copy has been provided to the resident and representative by 1/23/24
Type B 01/23/2024 Section Cited CCR87506(a)	1 2 3 4 5 6 7	87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information.	1 2 3 4 5 6 7	Licensee will review Title 22, Section 87506-Resident Records and ensure that all the required documents are in the resident files. Licensee will submit a signed written statement that Section 87506(a) was read and understood and all the information is contained in all the resident files by 1/23/24
	8 9 10 11 12 13 14		8 9 10 11 12 13 14

SUPERVISOR'S NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024

Link to Parent Document Below:

FACILITY NAME: HM SWEET HOME	FACILITY NUMBER: 197609604
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/16/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/17/2024 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored	1 2 3 4 5 6 7	Licensee will ensure that all medications are stored in a locked cabinet or place that is not accessible to persons other than staff responsible for the supervision of the centrally stored medications. Licensee will provide in-service training to staff who handle medications by 1/23/24
	8 9 10 11 12 13 14	medications. This requirement was not met as evidenced by: Resident #1's insulin was observed stored on the refrigerator door in it's orignal box and was not stored in a locked box located in the refrigerator. Also, Resident #1 has Metformin and supplements stored on the night stand	8 9 10 11 12 13 14	*****insulin was moved to a locked black box when it was brought to staff's attention******
Type A 01/17/2024 Section Cited HSC1569.618(a)	1 2 3 4 5 6 7	Administration and management of residential care facilities:(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with	1 2 3 4 5 6 7	Licensee will submit a written plan of action to the Department as to how she will be available at the facility during hours by 1/17/24 until a knowledgeable Administrator can be designated to manage the facilty.
	8 9 10 11 12 13 14	notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement was not met as evidenced by the Administrator has full time employment and is not available during business hours	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Kristin Heffernan LICENSING EVALUATOR NAME: Christine Yee LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024