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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609659
Report Date: 07/11/2024
Date Signed: 07/11/2024 02:32:32 PM


Document Has Been Signed on 07/11/2024 02:32 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 2FACILITY NUMBER:
197609659
ADMINISTRATOR:SRMIKYAN, LUSINEFACILITY TYPE:
740
ADDRESS:6460 VARNA AVETELEPHONE:
(818) 616-4103
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 6DATE:
07/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Marina BekyanTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with staff and explained the reason for the visit. The Coordinating Manager, and the licensee arrived shortly thereafter, and the LPA explained the reason for the visit.

The LPA and the 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.

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. The 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 LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level, 72 degrees.
RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Hot water measured at 117.0 degrees Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout bathrooms and facility to promote hand washing.
COMMON AREAS: The LPA observed the common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 05/15/2024. At 1:35 p.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.

Continues on LIC 809-C…

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SWEET HOME SENIOR LIVING 2
FACILITY NUMBER: 197609659
VISIT DATE: 07/11/2024
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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. No bodies of water noted. Cleaning supplies and disinfectants are kept in locked in a storage area.

RECORDS: Records review began at 12:15 p.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 1:45 p.m.; medications are centrally stored and locked in a cabinet near the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has 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 LPA reviewed the following documents:


- LIC500 Personnel Report
- LIC9020 Client Roster

Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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