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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608083
Report Date: 05/31/2024
Date Signed: 05/31/2024 02:52:07 PM

Document Has Been Signed on 05/31/2024 02:52 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/
DIRECTOR:		ARUTYUNYAN, TINAFACILITY TYPE:
740
ADDRESS:10150 MELVIN AVETELEPHONE:
(818) 970-9586
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 5DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Hermon LedesmaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Herman Ledesma, and explained the reason for the visit. Currently the administrator is out, but Hermon is designee to sign off on the licensing report.

At approximately 12:15pm, with the assistance of staff, LPA took a tour of the physical plant. The facility is a one story building, licensed to serve residents age 60 and above. Required postings were observed in the entry area. The smoke alarms are hardwired. The carbon monoxide detector is located by staff workstation. There is one fire extinguishers, located in the kitchen. It was purchased on September 12, 2023.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food sealed and properly stored. Knives were stored in a locked drawer. No cleaning supplies were observed.

Bedrooms: There are six (6) bedrooms. Five (5) are designated for residents' use. One bedroom (#6) is reserved for staff. Bedroom #2 is shared. Bedrooms #1 and numbers 3 to 5 are private. Bedrooms, in use by the residents were observed to be properly furnished with appropriate beddings and linens with 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 between 114 and 118 degrees Fahrenheit. No cleaning supplies were observed in either bathrooms during the day of the inspection.

Common Areas: These included the living room, family room and dining area. The living room was furnished with three couches and a table. The family room is furnished with four (4) recliners, one (1) chair, a table
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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 2
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: 05/31/2024
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and television. The dining room table is large enough to seat up to six (6) individuals. Furniture were observed to be in good repair. Floors were mopped and clean. Exits and Passageways were clear.

Surrounding Grounds: The backyard was large enough to hold outdoor activities when the weather permits. LPA checked the side gate to insure no locks installed, and that it is clear to exit/evacuate in case of an emergency. The outdoor area was free of hazards.

Laundry area: The laundry area is located adjacent to the garage. No cleaning supplies or detergents present during inspection. Cleaning supplies and detergents are kept in the garage, that has a locked entry.

Staff Workstation/Office: There is a staff workstation located at the corner of the living room.

Resident Files: Resident files are kept in cabinet in the living room. LPA reviewed files to insure compliance.

Staff Files: Staff files are also kept in the same cabinet where resident files are maintained. LPA conducted a file review of staff records to insure forms and training are up to date.

Medications: Medications are stored in a locked cabinet in the kitchen. Medication and Medication Records were reviewed for proper storage and documentation.

Garage: The garage is attached to the building. It is used for storage space to keep cleaning supplies and detergents. Entry to garage is kept locked at all times.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed, but one advisory for a technical violation was issued today.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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