197609659-7-29-2023-29-AS-EPEI-CU7PFX-20230729111727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609659
Report Date: 07/29/2023
Date Signed: 07/29/2023 11:18:05 AM

Document Has Been Signed on 07/29/2023 11:18 AM - 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:	07/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Lusine Srmikyan, Administrator		TIME COMPLETED:	11:30 AM

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 8:20 a.m., the LPA met with staff and explained the reason for the visit. At 8:51 a.m., the Coordinating Manager and the Administrator arrived at the facility. At 9:00 a.m., the LPA, along with the Administrator 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 9:01 a.m., hot water measured at 113.9-degree Fahrenheit. Medications and first aid kits are located in a locked cabinet near the kitchen area. BEDROOMS: The facility is a single-story residential home with four (4) bedrooms and four (4) bathrooms, three (3) for resident's use and one (1) for staff/public use. 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 are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 9:08 a.m., hot water measured between 108.0 and 110.1-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout bathrooms and facility to promote handwashing. 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 last serviced on 05/01/2023. At 9:12 a.m., fire alarms/ carbon monoxide detectors were tested and functioned properly. Laundry units are located in one of the hallways. Night lights were present in the hallways and passages. 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: 07/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 07/29/2023

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
26
27
28
29
30
31
32

OUTDOOR SPACE: At 10:21 a.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. There are no bodies of water on the premises. There are two locked sheds in the back patio that contain cleaning solutions, chemicals and other hazardous items.

Between 9:15 a.m. and 9:40 a.m., the LPA conducted interviews with three (3) staff and three (3) residents.
RECORDS: At 9:45 a.m., the LPA conducted a personnel file review for all staff regularly scheduled and reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. At 9:47 a.m., the Administrator explained that the annual training's have been completed however, the training documentation is not at the facility. The LPA had a discussion with the Administrator regarding the training documentation available for review. The Administrator’s certificate is active and expires on 10/07/2023. Remaining personnel files reviewed were observed to be in compliance.

Due to time constraints the LPA will return to complete the annual at a later date.

No deficiencies were observed at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2