197610420-9-15-2023-31-AS-MCAA-CVPQ7P-20230915115529

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610420
Report Date: 09/15/2023
Date Signed: 09/15/2023 11:55:38 AM

Document Has Been Signed on 09/15/2023 11:55 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SWEET HOME SENIOR LIVING 4		FACILITY NUMBER:	197610420
ADMINISTRATOR:	SPRY, NAIRA		FACILITY TYPE:	740
ADDRESS:	17259 BALLINGER ST		TELEPHONE:	(818) 419-5989
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 0	DATE:	09/15/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Naira Spry, Lusine Srmikyan		TIME COMPLETED:	12:00 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 (LPAs) Huma Rahimi, Leslie Ngo-Castaneda, and Michael Cava conducted a Pre-Licensing Inspection with the applicant representative, Lusine Srmikyan and administrator, Naira Spry. In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on March 13, 2023. The facility is a one story building with six (6) bedrooms and three and a half bathrooms (3 1/2). A fire clearance was approved on July 6, 2023 for four (4) non-ambulatory, one (1) ambulatory, and one (1) bedridden for a total capacity of six (6) residents. The applicant is also requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detector are dual and inter-connected. The facility has two new fire extinguishers, one located in the garage and one in the kitchen. Both were purchased on April 29, 2023. A tour of the physical plant was initiated at approximately 9:20am and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There were adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives and medications will be kept separately in a locked drawer. Also observed in the kitchen is an additional dining table, large enough to seat six (6) individuals. BEDROOMS: There are six (6) bedrooms designated for client use. All six rooms are designated for private use. At this time, Room #3 is used as the model bedroom. Room #3 was equipped with bed, night stand chair, dresser bedding and linen. Rooms #1, #2, #4, #5 and #6 were not furnished at this time. Rooms were observed to have sufficient lighting and closet space. Per STD 850, Bedroom #1 is Ambulatory only. Bedrooms #2 to #6 are cleared for non-ambulatory, with either room #2 or room #3 cleared for one bedridden (total) only.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SWEET HOME SENIOR LIVING 4	FACILITY NUMBER: 197610420
	VISIT DATE: 09/15/2023

NARRATIVE

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BATHROOMS: The facility has three and one-half (3 1/2) bathrooms. Bedroom #3 has it's own bathroom. Water temperature in this bathroom measured 118.8 degrees. There are two other hallway bathrooms designated for resident use. Water temperature was measured at 105 degrees. There is also a half bathroom designated for staff and guests located be the front entrance.

COMMON AREAS: These included the living and dining room area. The living room was equipped with couch, a television, tables and chairs. There are two fireplace with a screen. Both are non-operational. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate six (6).

LAUNDRY ROOM: The laundry room is located in the garage, which will be locked at all times.

MEDICATIONS: Medications will be centrally stored and locked in the kitchen with a complete first aid kit and manual.

OFFICE/STAFF WORKSTATION: Staff workstation is located at the entry, where resident and staff files will be maintained in a locked filing cabinet.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is a water pond that is fenced all around with a gate that will be kept locked at all times. The fence surrounding the swimming pool is approximately 5 feet high all around its parameters. You will need a key to unlock the padlock to gain entry to the swimming pool as it is kept locked at all times.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023

LIC809 (FAS) - (06/04)

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