197609659-6-22-2022-29-AS-EPEI-CFMSSS-20220622140825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609659
Report Date: 06/22/2022
Date Signed: 06/22/2022 02:09:00 PM

Document Has Been Signed on 06/22/2022 02:09 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 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:	06/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:08 PM
MET WITH:	Lusine Srmikyan, Administrator		TIME COMPLETED:	02:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 12:03 p.m., the LPA was greeted and screened by staff. At 12:05 p.m., the LPA met with Coordinating Manager, Marine Bekyan and explained the reason for the visit. At 1:10 p.m., the Administrator, Lusine Srmikyan arrived at the facility. This annual had a specific emphasis on infection control practices and procedures. At 12:22 p.m., the LPA, along with Coordinating Manager, Marine Bekyan 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. 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. At 12:25 p.m., hot water measured at 105.4-degree Fahrenheit. Medications and first aid kits are located in a locked cabinet near the kitchen area. 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. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 12:43 p.m., fire alarms and carbon monoxide detectors were tested and functioned properly. 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. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

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
	VISIT DATE: 06/22/2022

NARRATIVE

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RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 12:35 p.m., hot water measured at 106.0-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels.

OUTDOOR SPACE: At 12:31 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Coordinating Manager 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 LPA observed a 30-day 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.

At 12:14 p.m., the LPA conducted Infection Control mitigation module with the Coordinating Manager.

No deficiencies were observed at this time. Exit interview conducted with the Administrator. Report issued and a copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022

LIC809 (FAS) - (06/04)

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