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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609847
Report Date: 11/05/2022
Date Signed: 11/05/2022 12:51:44 PM


Document Has Been Signed on 11/05/2022 12:51 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:SWEET HOME SENIOR LIVING 1 FACILITYFACILITY NUMBER:
197609847
ADMINISTRATOR:NARE NERSISYANFACILITY TYPE:
740
ADDRESS:6458 VARNA AVENUETELEPHONE:
(818) 666-7601
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 2DATE:
11/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lusine Srmikyan, LicenseeTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 11:30 a.m., the LPA was greeted and screened by staff. At 11:30 a.m., the LPA met with the Licensee and the Coordinating Manager. This annual had a specific emphasis on infection control practices and procedures.

At 11:30 a.m., the LPA, along with the Administrator 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. At 11:32 a.m., hot water measured at 112.5-degree Fahrenheit. Medications and first aid kits are located in a locked kitchen cabinet.

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.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 11:35 a.m., hot water measured at 108.3-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels.

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 purchased on 06/22/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 11:33 a.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Continued on LIC 809-C.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2022
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 1 FACILITY
FACILITY NUMBER: 197609847
VISIT DATE: 11/05/2022
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OUTDOOR SPACE: At 11:36 a.m., the LPA observed the front 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. Passageways were free and clear from obstruction.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee and the Coordinator Manager regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for temperature checks, and a sanitation station. The LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. Exit interview conducted and report issued and a copy of the report was provided via email.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2022
LIC809 (FAS) - (06/04)
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