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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609658
Report Date: 09/23/2023
Date Signed: 09/23/2023 04:58:56 PM


Document Has Been Signed on 09/23/2023 04:58 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:SWEET HOME SENIOR LIVING 3FACILITY NUMBER:
197609658
ADMINISTRATOR:LUSINE SRMIKYANFACILITY TYPE:
740
ADDRESS:6462 VARNA AVETELEPHONE:
(818) 666-1622
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 4DATE:
09/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Marine BekyanTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct a required annual visit. Upon arrival LPA was greeted by staff. Staff contacted the facility Coordinating Manager, Marine Bekyan who arrived shortly after LPA. Reason for visit was explained. The Administrator was not available at the time of the visit. Coordinating manager, Marine Bekyan is authorized to sign the report.

At approximately 12:30 p.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.
BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms observed clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap, and paper towels. Hot water temperature is maintained within required range (105-120*f). Hot water temperature tested in residents bathroom was 108.5*f. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and purchased on 06/22/2022. Required posting observed through out the facility. Smoke/carbon monoxide detectors were tested and functioned properly. OUTDOOR SPACE: the back and front patio is set up for resident use. There is a gate on the side of the house designated for an emergency exit.

Staff and resident files reviewed at approximately 1:15p.m. - All required forms observed complete and updated. Medications and first aid kits are located in a locked kitchen cabinet. Resident medications and records reviewed at approximately 2pm. No deficiencies were observed at this time.

Exit interview conducted and report issued. A copy of the report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2023
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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