197609845-1-31-2022-29-AS-EPEI-CB7U2C-20220131141144

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609845
Report Date: 01/31/2022
Date Signed: 01/31/2022 02:13:36 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 FACILITY		FACILITY NUMBER:	197609845
ADMINISTRATOR:	NARE NERSISYAN		FACILITY TYPE:	740
ADDRESS:	6456 VARNA AVENUE		TELEPHONE:	(818) 666-7598
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 0	DATE:	01/31/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	LUSINE SRMIKYAN, Licensee		TIME COMPLETED:	02:15 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 1:10 p.m. LPA was greeted and screened by Licensee. This annual had a specific emphasis on infection control practices and procedures. At 1:21 p.m. LPA and Licensee began the physical plant tour inside and outside to ensure there are no health and safety hazards and facility is in compliance with the Title 22 Regulations. KITCHEN: At 1:22 p.m., LPA observed the kitchen area. Knives are stored in the locked kitchen cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:35 p.m., kitchen hot water temperature measured at 105.3-degree Fahrenheit. Medications are located in a locked kitchen drawer. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in a kitchen cabinet. BEDROOMS: At 1:26 p.m., LPA observed multiple resident bedrooms. Currently the facility has no residents, but the rooms are furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Passageways were free and clear from obstruction. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skids mats. At 1:36 p.m., LPA observed hot water to be measured at 108.0-degree Fahrenheit. COMMON AREAS: At 1:29 p.m., LPA observed common areas to be relatively clean and properly furnished. Required signs such as the license and complaint poster are posted near the front entrance. Signs are posted throughout facility to promote handwashing, cough/sneeze etiquette, and physical distancing. LPA observed the fire extinguisher to be fully charged and purchased on 03/04/2021. Continued on LIC 809C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022

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 FACILITY	FACILITY NUMBER: 197609845
	VISIT DATE: 01/31/2022

NARRATIVE

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Continued from LIC 809C.

OUTDOOR SPACE: LPA observed the backyard, which has a covered outdoor area for resident use. The facility has a side gate with a latch for emergency exits.

INFECTION CONTROL: During today’s visit, the LPA spoke with Licensee 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 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’s policies and procedures as it pertains to infection control are adequate.

Between 1:12 p.m. – 1:20 p.m., LPA conducted Infection Control mitigation module with Licensee.

No deficiencies cited. Exit interview conducted. 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: 01/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022

LIC809 (FAS) - (06/04)

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