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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609604
Report Date: 12/23/2024
Date Signed: 12/23/2024 03:15:27 PM

Document Has Been Signed on 12/23/2024 03:15 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: 5DATE:
12/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Elena KordonskiyTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20241217105630). The purpose of the visit is to issue citations for deficiencies observed during the initial complaint investigation.

During the visit on 12/23/2024 between 11:35AM – 12 PM, LPA conducted a medication review for five (5) out of five (5) current residents and one (1) former resident. LPA observed two (2) medication boxes for Resident #1 (R1) without a label. Administrator Elena Kordonskiy stated that the two boxes were taped together as they are the same medication and the top of the box where the label was, was thrown away. At 12:02PM, LPA observed accessible medications on a shelving unit in the kitchen. Administrator stored the accessible medications in the locked centrally stored medication cabinet in the kitchen. Between 12:02PM – 12:10PM, LPA observed eight (8) medications of former residents that were retained at the facility and not properly destroyed. Administrator properly destroyed the medications during the visit. At 12:10PM, LPA observed medications for Resident #2 (R2) stored in a pill box organizer and not in its original packaging with labels. Administrator destroyed the unlabeled medications for R2.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 12/23/2024 03:15 PM - It Cannot Be Edited


Created By: Angela Barutyan On 12/23/2024 at 01:53 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: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2024
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care (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 medication. This requirement is not met as evidenced by:
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Administrator stored medications in the locked and inaccessible medication cabinet in the kitchen. POC cleared during visit.
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Based on observation, the licensee did not comply as LPA observed medications accessible on shelving unit in the kitchen which posed an immediate health, safety, or personal rights risk to persons in care.
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Type B
12/31/2024
Section Cited
CCR87465(i)

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87465 Incidental Medical and Dental Care (i) Prescription medications which are not taken with the resident upon termination of services...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident... This requirement was not met as evidenced by:
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Administrator properly destroyed medications during visit. POC cleared during visit.
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Based on observation, record, and medication review, the licensee did not comply as eight (8) medications for former residents were observed at the facility not properly destroyed which posed a potential health, safety, and personal rights 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/23/2024 03:15 PM - It Cannot Be Edited


Created By: Angela Barutyan On 12/23/2024 at 02:05 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: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2024
Section Cited
CCR
87465(h)(5)

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87465 Incidental Medical and Dental Care (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
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Administrator destroyed the unlabeled medications during the visit. POC cleared.
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Based on observation, the licensee did not comply as medications for R2 were observed in a scheduled pill box and not in its orginal labeled container which posed an immediate health, safety, or personal rights risk to persons in care.
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Type B
12/31/2024
Section Cited
CCR87465(h)(4)

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87465 Incidental Medical and Dental Care (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
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Administrator stated they will attach the doctor's order to the unlabeled boxes. Administrator will also submit a signed statemement of understanding of the section cited to CCL by 12/24/2024.
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Based on observation and medication review, the licensee did not comply as two medication boxes were observed without labels which poses a potential health, safety, or personal rights 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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
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