<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607711
Report Date: 08/22/2022
Date Signed: 08/31/2022 07:25:07 AM

Document Has Been Signed on 08/31/2022 07:25 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: 4DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Tina Arutunyan/ AdministratorTIME COMPLETED:
02:30 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 (LPA) Patrick Shanahan, arrived at the facility in order to conduct an infection control annual. The LPA was greeted by a facility staff, who was observed not to be wearing a mask. The LPA entered the home and was not screen per the covid-19 protocol. LPA also observed a visitor at the facility who was also not screened prior to being allowed entry.

LPA toured the facility and observed in room number 3 a resident with a full bed rail. The administrator did not have a prescription for the bed rail during the visit. A tour of the kitchen also revealed that the facility did not have a sufficient amount of perishable food for the residents in care. At about 2:10 PM, groceries were observed to be delivered to the home and a copy of the receipt was emailed to LPA.

The smoke alarm and the carbon monoxide detectors were tested, and functioned properly. The fire extinguisher was last serviced on 8/23/21 and was functional.

The LPA was also able to go through the cash recourses for one resident and the amounts appeared to add up and no discrepancies were observed.

Exit interview conducted, deficiencies cited and report issued
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 08/31/2022 07:25 AM - It Cannot Be Edited


Created By: Patrick Shanahan On 08/22/2022 at 01:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: OUR SWEET HOME INC
FACILITY NUMBER: 197607711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87470(c)(1)(f)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA Observation, the licensee did not comply with the section cited above by not screening visitors, following coid protocols or wearing masks which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
1
2
3
4
Administrator agrees to hold an inservice with staff regarding this requirement and submit a sign in sheet and training materials as POC
Type A
Section Cited
HSC
87608(a)(5)(b)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above by using a full bed rail without a prescription which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
1
2
3
4
The administrator will provide a copy of the prescription of the bed rail and put into writing her understanding of this regulation
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/31/2022 07:25 AM - It Cannot Be Edited


Created By: Patrick Shanahan On 08/22/2022 at 01:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: OUR SWEET HOME INC
FACILITY NUMBER: 197607711

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above iby not having a sufficient amount of perishable foor which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
1
2
3
4
Administrator agrees to provide the LPA with a receipt of the food purchased
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3