197609659-5-24-2021-29-AS-EPEI-C3BTBT-20210524143540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609659
Report Date: 05/24/2021
Date Signed: 05/24/2021 02:38:21 PM

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 2		FACILITY NUMBER:	197609659
ADMINISTRATOR:	SRMIKYAN, LUSINE		FACILITY TYPE:	740
ADDRESS:	6460 VARNA AVE		TELEPHONE:	(818) 616-4103
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	05/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Lusine Srmikyan		TIME COMPLETED:	02:45 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Emily Peraldi and Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 9:43am. When the LPAs arrived, there was two staff and five residents present. Administrator, Lusine Srmikyan arrived around 10:10am.

The LPAs 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.

OUTDOOR SPACE: The LPAs observed the backyard, which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit.

KITCHEN: The LPAs observed the kitchen/dining area at 10:33am. Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:34am, the LPAs observed expired milk in the refrigerator. The staff removed and disposed of the item upon observation.

BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid mat. At 10:17am, the LPAs observed Lysol disinfecting spray, over the counter medications and personal hygiene items in the restroom inside Bedroom 1. The staff removed and locked the items upon observation.

Records: LPAs requested files for all current residents at 10:49am. Per review of the Physician's Reports, 1 out 5 residents (R1) were identified at being at risk if allowed access to personal grooming and hygiene items. Also, 2 out of 5 residents (R2, R3) need an updated appraisal.

Cont. on 809C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SWEET HOME SENIOR LIVING 2	FACILITY NUMBER: 197609659
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as there were disinfectants, over-the-counter medications, and personal hygiene items accessible, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 05/24/2021
	Plan of Correction
1 2 3 4	Administrator agreed to lock up the above items. Administrator agreed to keep above items inaccessible to residents. Plan of Correction met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SWEET HOME SENIOR LIVING 2	FACILITY NUMBER: 197609659
	VISIT DATE: 05/24/2021

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INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

The LPAs observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

The following recommendations were made:

- Reminder to staff - when visitors come in, prompt them to check temperatures, encourage visitors to sign in, etc. Staff did not do this with the analysts upon arrival.
- Upon entry, the LPAs observed one staff not wearing a face covering. However, staff immediately complied and put on a covering. A reminder to inform staff that they need to wear face covering throughout entire shift (unless eating/drinking, etc)
- Posting Provider Information Notices (PINs) and educating staff, residents, and families on changing policies and procedures from the Department.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC809 (FAS) - (06/04)

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