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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 05/15/2024
Date Signed: 05/15/2024 05:19:57 PM

Document Has Been Signed on 05/15/2024 05:19 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:HM SWEET HOMEFACILITY NUMBER:
197609604
ADMINISTRATOR/
DIRECTOR:		NADRIAN, ASMIKFACILITY TYPE:
740
ADDRESS:6215 BLUEBELL AVENUETELEPHONE:
(818) 903-6302
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 6CENSUS: 6DATE:
05/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:43 PM
MET WITH:Arshalouis Manoukyan, FriendTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
NARRATIVE
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced case management visit due to the deficiencies observed during a visit to the facility today. Asmik Nadrian, Administrator was not able to conduct today's visit and sent over a friend of a resident, Arshalouis Manoukyan to conduct the visit. The reason for today's visit was explained.

The following deficiencies were noted on today's visit:
  • the friend of the resident, Arshalouis Manoukyan, who was present at the facility to act as the designated representative of the Administrator and to conduct the visit at the request of the Administrator does not have a criminal record clearance.
  • files requested on today's visit could not be provided as the key to the locked cabinet containing the residents and staff files were with the Administrator. Staff present at the facility do not have keys or access to the files.



Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Immediate CIVIL PENALTIES were assessed.


Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was provided
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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 05/15/2024 05:19 PM - It Cannot Be Edited


Created By: Christine Yee On 05/15/2024 at 04:05 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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2024
Section Cited
CCR
87355(e)

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Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health andSafety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption
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The Licensee will ensure that all staff, volunteers, or persons who assist in the operations of the facility shall prior to volunteering in an official capacity on behalf of the Administrator should have a obtained a criminal record clearance prior to being present at the facility.
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 as required by the Department or ..This requirement was not met as evidenced by:
Arshalouis Manoukyan, at the request of the Administrator conducted today's visit but does not have a criminal record clearance. Civil Penalties of $100 was assessed for today's visit
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Licensee will take steps to obtain a criminal record clearance if Arshalouis Manoukyan will be calledl upon for regular assistance with the facility and for translation services. Provide a written statement as to how the Licensee will correct this deficiency.
Type B
05/22/2024
Section Cited
CCR87506(a)

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Resident Records
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.
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The Licensee will ensure that the Department is able to be provided with requested files within a reasonalble amount of time for review. Provide a written statement as to how the Licensee will ensure that complete staff and resident files are available for Department review by 5/2224.
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This requirement was not met as evidenced by: Files requested on today's visit to the facility was not provided since staff could not access the locked cabinet containing resident and staff files as the keys were taken home by the Administrator who was not able to conduct today's visit
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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