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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608083
Report Date: 03/17/2022
Date Signed: 03/17/2022 02:00:48 PM

Document Has Been Signed on 03/17/2022 02:00 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 INC #2FACILITY NUMBER:
197608083
ADMINISTRATOR:ARUTYUNYAN, TINAFACILITY TYPE:
740
ADDRESS:10150 MELVIN AVETELEPHONE:
(818) 970-9586
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 5DATE:
03/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Tina Arutyunyan TIME COMPLETED:
02:10 PM
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At 12:10 p.m Licensing Program Analyst (LPA) Joscelyn Martinez conducted an announced annual inspection. Upon arrival LPA met with staff Hermon Ledesma and later met with Administator Tina Arutyunyan. A physical tour of the facility was conducted and the following was observed: Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, staff took LPAs’ temperature and was asked to sign-in the visitor’s log. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: LPA Martinez observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Garbage cans have tight fitting covers in the kitchen. Sharps and medications are centrally stored in a locked area. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested at 12:46 p.m. and appear to be functional. Fire extinguisher has a purchase date of 08/23/2021. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 72.0 F. Residents Rooms: There are six (6) rooms which five (5) are designated for resident use. There is one live in staff. All the residents’ bedrooms were toured and appear to be clean and properly furnished. LPAs observed additional bedding and linens sufficient for all of the residents. Trash cans in residents’ bedrooms did not have tight fitting lids. LPA stated they need to add tight fitting lids to the trash cans to all bedrooms. Bathrooms: There are three (3) bathrooms which of two (2) are designated for resident use. LPA observed all bathrooms to have grab bars and non-skid mats. At 12:50 p.m. the hot water was tested and measured at 130.8 F which is not in regulation. LPA Martinez reminded staff that water needs to measure between 105-120 degree Fahrenheit. One of the bathrooms floor around the toilet is in disrepair and needs to be changed.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2022
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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Document Has Been Signed on 03/17/2022 02:00 PM - It Cannot Be Edited


Created By: Joscelyn Martinez On 03/17/2022 at 01:16 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 #2
FACILITY NUMBER: 197608083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2022
Section Cited

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Maintenance and Operation(e)(2) Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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This requirement is not met as evidenced by:Water temperature meaured at 130.8 degree F. Based on water temperature measurement, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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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:Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/17/2022 02:00 PM - It Cannot Be Edited


Created By: Joscelyn Martinez On 03/17/2022 at 01:26 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 #2
FACILITY NUMBER: 197608083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2022
Section Cited

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8730 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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This requirement is not met as evidenced by: Garage is overfilled with bulk items, Patio flooring poses a tripping hazard to the residents and one bathroom floor is in disrepair, which poses a health, safety or personal rights risk to persons in care.
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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:Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2022


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 #2
FACILITY NUMBER: 197608083
VISIT DATE: 03/17/2022
NARRATIVE
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Garage: There is an additional laundry room that leads into the garage. The attached garage remains locked and is being used for additional storage. Garage is overfilled with bulk items and poses a risk to staff going inside. Chemicals are locked inside the garage. Outside areas: LPAs toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Outside patio is in disrepair. Patio floor is warped and lifted which poses a tripping hazard to the residents. LPA observed an old mattress, broken trash can bin, and a shopping cart near the side of the house. LPA Martinez stated these items need to be thrown out.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC809 (FAS) - (06/04)
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