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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607711
Report Date: 08/06/2021
Date Signed: 08/06/2021 11:15:33 AM

Document Has Been Signed on 08/06/2021 11:15 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:OUR SWEET HOME INCFACILITY NUMBER:
197607711
ADMINISTRATOR:ARUTYUNYAN, TINAFACILITY TYPE:
740
ADDRESS:16518 DEVONSHIRE STTELEPHONE:
(818) 970-9586
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 6DATE:
08/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rodolfo TriponTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility 9:00 to conduct an unannounced infection control inspection/visit. Upon arriving, LPA was greeted by caregiver Rodolfo Tripon; who allowed LPA to enter the facility. According to Rodolfo, there have not been any active or past COVID cases at the facility, and all staff and residents have been vaccinated. The current census is (6). LPA's temperature was taken, and LPA observed the .cleaning table, with hand sanitizer at the front door. LPA observed both staff to have full mask covering. COVID-19, CDC, Department of Public Health, and Licensing postings on the walls throughout the facility. Rodolfo contacted Administrator Tina Arutyunyan, LPA spoke to over the facility telephone. Administrator could not be present during the visit, due to being out of town.

The infection control inspection began with the caregiver Rodolfo, who escorted LPA throughout the facility. The facility has (6) bedrooms; with (1) room for staff, and (1) shared room. The common areas were observed to be clean, including bathrooms, with soap and towels, and hand washing signs visually posted. LPA conducted a mitigation plan review with the caregiver Rodolfo, in order to obtain information on how the facility has implemented the department's mitigation plan; who could only provide limited information pertaining to COVID procedures.

The facility has documentation of all vaccination records and other pertinent information pertaining to COVID-19. Visitation is allowed, in certain areas of the facility, and everyone is screened prior to entry. Residents do not wear masks inside the facility; only when they leave. Residents eat together in the dining room, and they continue to social distance. LPA discussed with the caregiver, that even though, everyone in the facility has been vaccinated, safety measures should continue to be implemented. LPA could not obtain personnel issues, such as staffing and sick leave policies, since Administrator was not available.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2021
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: OUR SWEET HOME INC
FACILITY NUMBER: 197607711
VISIT DATE: 08/06/2021
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PPE, cleaning, and other related supplies were inspected. The facility continues to implement the best practices for their facility; which has kept them COVID-19 free. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted with caregiver Rodolfo, and copy of report will be emailed to Administrator.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC809 (FAS) - (06/04)
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