197609658-8-30-2024-29-AS-EMOY-D8MTJR-20240830144646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609658
Report Date: 08/30/2024
Date Signed: 08/30/2024 02:47:10 PM

Document Has Been Signed on 08/30/2024 02:47 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:	SWEET HOME SENIOR LIVING 3		FACILITY NUMBER:	197609658
ADMINISTRATOR:	LUSINE SRMIKYAN		FACILITY TYPE:	740
ADDRESS:	6462 VARNA AVE		TELEPHONE:	(818) 666-1622
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	08/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Lusine Srmikyan		TIME COMPLETED:	03:00 PM

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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:10 a.m. Upon arrival, LPA Mosley was greeted by staff and called the administrator to inform them of the visit. The administrator arrived shortly thereafter. The LPA met with LUSIER SRMIKYAN, licensee / Administrator and BEKYAN MARINE, coordinator / manager and explained the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Pertinent documents were obtained including LIC 500, LIC 9020A, LIC 610D, and a copy of current liability insurance.

KITCHEN: The LPA inspected the kitchen/food service area at 9:26 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 109 degrees Fahrenheit at 9:32 a.m.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 9:51 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 05/15/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 6/21/2024 and conducted quarterly. Activities were observed in the common areas.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SWEET HOME SENIOR LIVING 3	FACILITY NUMBER: 197609658
	VISIT DATE: 08/30/2024

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Report Continued from LIC 809...
RESTROOMS: The two (2) resident restrooms one (1) designated as a shared restroom and one (1) designated as a private bathroom. Both were clean, sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 10:02 a.m.-10:15a.m; the first, shared bathroom measured at 106.9 degrees Fahrenheit and the second, private bathroom measured at 108.6 degrees Fahrenheit, both within the required range.

BEDROOMS: There are three (3) total bedrooms in the facility; two (2) are designated as a shared room, one (1) is designated as private resident room. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

GARAGE/OUTDOOR: The garage is maintained locked at all times and designated as the facilities office. There is a washer and dryer on premises. LPA observed an adequate amount of emergency food and water supply at 9:55 a.m. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The outdoor area has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPAs observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.

RECORDS: Resident Records were reviewed beginning at 10:18 a.m. and personnel records at 11:30 a.m. five (5) out of five (5) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Four (4) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order with required forms observed complete and updated. INTERVIEWS: Three (3) staff interviews were conducted. Staff are knowledgeable of their responsibilities. Two (2) resident interviews were conducted. No concerns noted at the time of the visit.

MEDICATIONS: Medications review began at approximately 12:22 p.m. Medications and first aid kits are located in a locked kitchen cabinet. Medications for five (5) out of five (5) residents were reviewed. Medications reviewed were found to be administered as prescribed and documented on the centrally stored medication and destruction records.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

LIC809 (FAS) - (06/04)

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