197610420-9-4-2024-31-AS-GSAO-D8ST23-20240904142005

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610420
Report Date: 09/04/2024
Date Signed: 09/04/2024 02:20:31 PM

Document Has Been Signed on 09/04/2024 02:20 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 S.RO, 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: 4	DATE:	09/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Lusine Srmikyan		TIME COMPLETED:	02:30 PM

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On 09/04/2024 at 9:25 AM, Licensing Program Analyst (LPA) Gina Saucedo and Angelica Segovia conducted an unannounced, Annual Inspection and met with Lusine Srmikyan, Licensee. LPA asked for the census, staff and resident files.

The physical plant was toured inside and out at 11:50 am.

Living/Dining Room Area: LPA Saucedo observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 75 degrees Fahrenheit with a large television. There are several televisions and furniture for staff and residents for seating. They have two (2) fireplaces that have a covering, inaccessible to the residents. There also have a land-line telephone.

Bedrooms/Bathrooms: There are six (6) bedrooms. All six (6) bedrooms are used for residents. There are four (4) bathrooms. One (1) of the bedrooms has a private bathroom. In the hallway, there are closets that have extra linen. LPA observed the bedrooms to have bedding sheets, pillowcase, blankets, nightstands, televisions, and sufficient lighting for each of the resident’s room. The hot water temperatures were measured within regulations of 109 degrees. The showers have non-slip bathmats and grab bars.

There is also a signal system in the facility. There are two (2) fire extinguishers fully charged that expire on July-2025. One (1) is located in the kitchen area and one (1) is located in the garage.

Medications were kept in a locked drawer on your right-hand side of the kitchen. All medications were properly labeled and inaccessible to residents. The first aid kit is kept in this same closet.

Kitchen Area: LPA inspected the kitchen area. There is one (1) refrigerator which was clean and in good operation in this area. LPA observed sufficient supply of seven (7) day non-perishable and perishable foods in the cabinets. The knives/sharps were locked and inaccessible to the residents on your right-hand side.

LIC809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SWEET HOME SENIOR LIVING 4	FACILITY NUMBER: 197610420
	VISIT DATE: 09/04/2024

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Garage:The washer and dryer are kept in the garage area. The garage area has another refrigerator and fire extinguisher.

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility has a pool that is gated and locked and inaccessible to the residents. T

The carbon monoxide and the smoke detector were tested, and they were operable, interconnected.

Administration: The Liability Insurance was reviewed and will be renewed on 11/18/2024. There are several Covid 19 signs on the wall, YES, Emergency Disaster Plan, Personal Rights, Theft and Loss Policy.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Licensee.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

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