197609845-12-29-2023-29-AS-KHEN-CYZ2QV-20231229163633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609845
Report Date: 12/29/2023
Date Signed: 12/29/2023 10:55:27 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2021 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20211201154331

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: 5	DATE:	12/29/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Lusine Srmikyan, Licensee, Marine Bekyan		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.
Resident developed a rash while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 9:45 a.m., the LPA met with staff and explained the reason for the visit. At 10:15 a.m., the Licensee and Coordinating Manager arrived at the facility.

During the initial visit conducted on 12/02/2021 between 11:20 a.m. and 1:15 p.m., LPA Angel Ascencio conducted an interview with staff, conducted physical plant tour and obtained copies of pertinent documents. On 12/21/2023, at 1:50 p.m., LPA Peraldi conducted a telephonic interview with the Licensee. On 12/21/2023, at 3:10 p.m., LPA Peraldi attempted to conduct a telephonic interview with Resident #1’s (R1’s) case manager. Additionally, on 07/14/2023 and 12/21/2023, LPA Peraldi reviewed R1’s records.

Continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20211201154331

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 FACILITY	FACILITY NUMBER: 197609845
	VISIT DATE: 12/29/2023

NARRATIVE

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Regarding the allegations: Resident sustained an unexplained injury while in care and Resident developed a rash while in care. On 12/01/2023, the Department received a complaint alleging that Resident #1 (R1) had developed skin damage and right ankle rashes while at the facility and “was unable to provide meaningful history.” Per record review, R1 was admitted to the facility on 09/01/2021 and was on home health services. Interview with the Licensee revealed that R1 was on home health services for wound care. The Licensee stated that prior to R1’s death, that R1 changed from home health services to hospice services. Per record review, R1’s home health services included wound care for R1’s buttocks and coccyx area and stage 2 on right ankle. Based on record review, it’s unclear when R1’s rashes developed and if R1 had any injuries while in care at the facility. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

LIC9099 (FAS) - (06/04)

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