197609847-1-16-2025-29-AS-EMOY-DCYVTA-20250116154248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609847
Report Date: 01/16/2025
Date Signed: 01/16/2025 03:43:43 PM

Document Has Been Signed on 01/16/2025 03:43 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 1 FACILITY		FACILITY NUMBER:	197609847
ADMINISTRATOR/ DIRECTOR:	KAREN BABAYAN		FACILITY TYPE:	740
ADDRESS:	6458 VARNA AVENUE		TELEPHONE:	(818) 666-7601
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91401
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	01/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:24 PM
MET WITH:	Marine Bekyan - Coordinating Manager		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 1:24 p.m. Upon arrival, LPA Mosley was greeted by staff and Coordinating Manager. The LPA met with Marine Bekyan – Coordinating Manager and explained the reason for the visit. Lusine Srmikyan Licensee Representative was called and informed of the reason for this visit. The LPA 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.

KITCHEN: The LPA inspected the kitchen/food service area at 1:30 p.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. Chemical storage is kept locked under the sink. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 117.1 degrees Fahrenheit at 1:33 p.m.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 1:39 p.m., hardwire combination of smoke / carbon monoxide detector and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 05/15/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 12/20/2024. Activities were observed in the common areas. There is a laundry area with a washer and dryer. Laundry detergent was observed in a locked cabinet under the sink.

Report Continued on LIC 809C...

Kasandra Lopez	TELEPHONE: (818) 596-4343
Erica Mosley	TELEPHONE: (747) 230-3909
	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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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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 1 FACILITY	FACILITY NUMBER: 197609847
	VISIT DATE: 01/16/2025

NARRATIVE

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Report Continued from LIC 809...

RESTROOMS: There are Two (2) resident restrooms. One (1) is designated for private resident use and one (1) is a shared resident use. Resident restrooms were observed to be equipped with nonskid surfaces. Grab bars were observed in the bathrooms. The restrooms were sufficiently stocked with supplies and paper towels. The water temperature was measured in both resident restrooms from 1:32 p.m - 1:35 p.m and measured between 115.5-117.4 degrees Fahrenheit and within the required range.

BEDROOMS: There are three (3) total bedrooms in the facility; All three (3) are currently designed as private resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

GARAGE/BACKYARD: The garage is designed as the office and is maintained locked at all times. LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.

MEDICATIONS: Medications review began at approximately 2:44 p.m. The medications are in a locked drawer in the kitchen. Medications for three (3) residents were reviewed. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records.

RECORDS: Record review began at approx. 1:45 pm. Resident Records were reviewed beginning at 1:45 p.m. Three (3) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Personnel Records were reviewed beginning at 2:00 p.m. Four (4) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

Report Continued to LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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 1 FACILITY	FACILITY NUMBER: 197609847
	VISIT DATE: 01/16/2025

NARRATIVE

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Report Continued from LIC 809C...

INTERVIEWS: Two (2) staff interviews, and One (1) resident interview was conducted during the inspection. Staff interviews revealed that staff are knowledgeable in Resident right, different forms of abuse and reporting procedures. Resident interviews revealed that no concerns were voiced or noted at the time of the visit.

LPA obtained the following documents LIC 500 Personnel Roster, LIC 9020 Resident Roster, and current liability insurance.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was reviewed and provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

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