197609659-6-19-2025-29-AS-QHUH-DHSTZC-20250619151007

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609659
Report Date: 06/19/2025
Date Signed: 06/19/2025 03:10:35 PM

Document Has Been Signed on 06/19/2025 03:10 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 2		FACILITY NUMBER:	197609659
ADMINISTRATOR/ DIRECTOR:	SRMIKYAN, LUSINE		FACILITY TYPE:	740
ADDRESS:	6460 VARNA AVE		TELEPHONE:	(818) 616-4103
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91401
CAPACITY: 6		CENSUS: 3	DATE:	06/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:38 AM
MET WITH:	Lusine Srmikyan - Licensee		TIME VISIT/ INSPECTION COMPLETED:	03:30 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) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 11:38AM. The LPA met with the Licensee Lusine Srmikyan and Coordinating Manager Marine Bekyan and informed them of the reason for the visit. Entrance interview conducted. Beginning at 11:50AM, the LPA and Licensee 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. The facility is a single-story residential home on a shared property with another related facility. The following was observed: KITCHEN: The LPA observed knives stored inaccessible in a locked drawer near the sink. Kitchen appliances were clean and in operable condition. The facility had a supply of perishable and non-perishable food, as well as emergency food and water stored in the detached office. Food in the refrigerator and freezer were observed to be properly stored with labels and dates. Grocery shopping occurs every two (2) weeks, sometimes more when needed. Report Continued on LIC 809-D

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 2	FACILITY NUMBER: 197609659
	VISIT DATE: 06/19/2025

NARRATIVE

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BEDROOMS/RESTROOMS: There are four (4) total bedrooms: Bedrooms #1 and #4 are shared and Bedrooms #2 are #3 are private. Bedroom #4 is cleared for one (1) Bedridden resident and had a direct exit to the outside. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens and supplies were stored in each Bedroom located in cabinets. There are four (4) total restrooms in the facility: three (3) attached private resident restrooms and one (1) common restroom located in the hallway. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured between 109.6 degrees F and 116.6 degrees F which is within the required range per regulation.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There was an office/staff nook located in the dining area, with required postings and centrally stored medications in a locked cabinet. The facility maintained a comfortable temperature throughout the visit. A fire extinguisher was observed in the dining area and was last serviced on 04/16/2025. There was a laundry closet located in the hallway and contained laundry supplies. The laundry door remains locked when not actively in use and the machines were observed to be operational. Ramps were observed throughout the facility for wheelchairs.

OUTDOOR AREA: The surrounding grounds had multiple shaded patio areas equipped with furniture in good condition for resident and visitor use. The front yard had a driveway with a remote operated gate as well as a door for everyday use. There was one (1) emergency exit door located on one side of the facility. The other side of the facility had a locked side gate which contained a shed and general storage/equipment. All exits and passageways were free of obstructions. The LPA observed one (1) shed in the backyard that contained general storage and was locked. The facility had additional gates with access to the neighboring three (3) facilities that the Licensee also operates.

Report Continued on LIC 809-D

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

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 2	FACILITY NUMBER: 197609659
	VISIT DATE: 06/19/2025

NARRATIVE

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RECORDS: Record review began at 12:17PM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and 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 records were in order.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and reviewed annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 06/03/2025. Smoke and carbon monoxide detectors as well as fire door were tested at 1:53PM and were operational.

MEDICATIONS: Medication review began at 1:35PM. Medications are centrally stored and kept inaccessible. Medications were observed for three (3) residents. Medications were labeled and checked for expiration dates and were properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Four (4) staff and one (1) resident were interviewed. No complaints noted.

Documents obtained: LIC 500 and Resident Roster.

No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Quoc Huynh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC809 (FAS) - (06/04)

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