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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609845
Report Date: 01/27/2024
Date Signed: 01/27/2024 11:48:11 AM


Document Has Been Signed on 01/27/2024 11:48 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:SWEET HOME SENIOR LIVING FACILITYFACILITY NUMBER:
197609845
ADMINISTRATOR:KAREN BABAYANFACILITY TYPE:
740
ADDRESS:6456 VARNA AVENUETELEPHONE:
(818) 666-7598
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 6DATE:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lusine Srmikyan, LicenseeTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:15 a.m., the LPA met with staff and explained the reason for the visit. At 9:40 a.m., the Licensee arrived at the facility.

At 9:45 a.m., the LPA, along with the Licensee 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 and 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 9:47 a.m., hot water measured at 107.1-degree Fahrenheit. Medications and first aid kits are located in a locked kitchen drawer.

BEDROOMS: The facility is a single-story residential home with four (4) bedrooms and three (3) bathrooms for resident's 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 9:49 a.m., hot water measured between 104.8 and 109.8-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 10:19 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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SWEET HOME SENIOR LIVING FACILITY
FACILITY NUMBER: 197609845
VISIT DATE: 01/27/2024
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OUTDOOR SPACE: At 9:54 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.

Between 10:11 a.m. and 10:18 a.m., the LPA conducted interviews with one (1) staff and four (4) residents.
The Administrator’s certificate is active and expires on 03/16/2025

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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC809 (FAS) - (06/04)
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