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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609604
Report Date: 01/16/2024
Date Signed: 01/16/2024 04:56:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/08/2024 and conducted by Evaluator Christine Yee
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20240108222517
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: 5DATE:
01/16/2024
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Mariam Baghdoyan, StaffTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff administering medication not prescribed for a client
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) Christine Yee conducted an unannounced complaint visit to investigate the above allegation and was let into the home by Mariam Baghdoyan, staff. Marine Ashakyan, Staff was contacted and she arrived a little later to assist with the visit until 12:50pm and had to leave to take a family member to a doctor appointment. Asmik Nadrian, Administrator did not participate in today's visit since she holds a full time job and is not available during business hours.

During today's visit, LPA Yee reviewed all residents' files at 10:30am, reviewed all residents medications at 11:23am and conducted an interview with Marine Ashakyan,staff, at 11:07am and Resident #1 at 12:35am. Per information, received from staff interview and review of Resident #1's medication centrally stored in a plastic box, the medication bottles were observed labeled with Resident #1's name, the dosage and the frequency medication is dispensed. Per staff, they dispense medications as noted on the bottle and do not
Substantiated
Estimated Days of Completion:
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
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20240108222517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 197609604
VISIT DATE: 01/16/2024
NARRATIVE
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dispense any other medications. Resident #1 is not given someone else medication. Per file review, the facility does not keep written records of medications that are dispensed to the residents or refused by the residents. Per Marine and Asmik Nadrian, Administrator via telephone, the residents have not refused medications for the reason why there are no notes that resident's refused medications. Per interview with Resident #1, staff dispense medications. However, per visual observation of Resident #1's night stand, bottles of supplements such as Neuriva, Tumeric, Ginger, Soursop, stool softeners and a bottle of Metformin that was previously prescribed at a former home were observed. The bottle of Metformin in the resident's room is in addition to the Metformin already centrally stored. Per Resident #1, the doctor did not prescribe the supplements and is not aware of the resident's use of these supplements. The bottles of supplement were not labeled and no physicians' orders were observed in the resident's file to determine if the use of these supplements could be detrimental to the resident who takes prescribed medications. Facility staff are aware of Resident #1's use of the supplements and have not taken any steps to ensure that the supplements do not contraindicate with their prescribed medications.


Based on the information received on today's visit the above allegation is SUBSTANTIATED.

Deficiencies cited California Code of Regulations, Title 22, Division 6, Chapter 8.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240108222517
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 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
01/30/2024
Section Cited
CCR
87465(e)(1-4)
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(e) For every prescription and non- prescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall
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Licensee will ensure that all medications for which they provide assistance, there shall be a signed, dated written order from a physician, on a prescription blank maintained in the resident's file and a label on the medication. Licensee will contact all prescribing doctors to obtain a signed physician's order for all centrally stored
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 contain at least all of the following information.(1) The specific symptoms which indicate the need for the use of the medication.(2) The exact dosage.(3) The minimum number of hours between doses.(4) The maximum number of doses allowed in each 24-hour period.
Resident #1 takes supplements and there were no doctor orders observed on file
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medications including the supplements being taken by Resident #1 and maintain in all the residents' file. Submit emailed evidence that physician's orders have been obtained by1/30/24
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
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