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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608084
Report Date: 09/01/2021
Date Signed: 09/01/2021 03:00:27 PM

Document Has Been Signed on 09/01/2021 03:00 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 #3FACILITY NUMBER:
197608084
ADMINISTRATOR:ARUTYUNYAN, TINAFACILITY TYPE:
740
ADDRESS:21054 VINTAGE STTELEPHONE:
(818) 960-5224
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 6DATE:
09/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Saturnina Reyes/ StaffTIME COMPLETED:
03:20 PM
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Licensing Program Analyst's (LPA's) Patrick Shanahan and Nicholas Reed arrived at the facility in order to conduct an infection control annual. LPA's were greeted by facility staff and LPA temperatures were checked before being allowed entry.

The facility is following all covid -19 protocols and signs reminding staff and residents to wash their hands were observed throughout the facility and in the restrooms. All residents temperatures are taken twice daily and are documented.

A brief tour of the physical plant was conducted and no health and safety concerns were observed. The smoke alarms and carbon monoxide detectors were tested, and function properly. The kitchen was inspected and sufficient amounts of perishable and non perishable food was observed and properly stored.

No health and safety concerns were observed during the visit.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2021
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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