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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607711
Report Date: 03/17/2023
Date Signed: 03/17/2023 01:50:49 PM

Document Has Been Signed on 03/17/2023 01:50 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
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:
03/17/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Norma Alfeche, Manuel SorianoTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Michael Cava conducted Case Management (CM) visit and inspection of the facility to insure facility compliance. On May 27, 2022, a Non Compliance Conference (NCC) was held at the Woodland Hills Regional office. As a result of that NCC, the facility was placed on a three year compliance plan. LPA met with staff, Arlene Aragon and Manuel Soriano and explained the reason for the visit.

At approximately 10:45am, with the assistance of staff, LPA took a tour of the physical plant. The smoke alarms are hardwired. The carbon monoxide detector is installed in the dining room. The fire extinguisher is located in the kitchen. It is brand new. The purchase date is August 4, 2022.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. LPA did not observe any sharps or knives out in the open. They were properly stored and locked in a cabinet. Properly labeled medications were locked in one of the kitchen cabinets, along with the medication, staff and resident records.

Bedrooms: There were six (6) bedrooms designated for residents' use. Five (5) bedrooms are private amd one (1) is shared. All the bedrooms were properly furnished with appropriate beddings, linens and sufficient lighting.

Bathrooms: There are three (3) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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: OUR SWEET HOME INC
FACILITY NUMBER: 197607711
VISIT DATE: 03/17/2023
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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. There was enough space to hold outdoor activities for the residents in care. The laundry area is located by the living room. Cleaning supplies are stored and maintained locked there. Residents are not allowed to enter the laundry area.

Medications: Medication and Medication Records were reviewed for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the day's visit. Exit Interview Conducted and a Copy of this report was issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023
LIC809 (FAS) - (06/04)
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