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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608084
Report Date: 04/04/2022
Date Signed: 04/04/2022 12:34:48 PM

Document Has Been Signed on 04/04/2022 12:34 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: 5DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tina Arutyunyan TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced annual inspection. Upon arrival LPA met with staff and later met with Administrator Tina Arutyunyan. The purpose of the visit was explained.

At 11:00 a.m LPA conducted a physical tour of the facility 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 LPA’s 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. Sharps and medications are centrally stored in a locked area. Garbage can has a tight-fitting lid in the kitchen. Smoke detectors/carbon monoxide are located throughout the facility. Smoke detectors and carbon monoxide detectors were tested at 11:25 a.m. and appear to be functional. Fire extinguisher has a purchase date of 03/17/2022. 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 are two (2) live in staff. Four (4) bedrooms are private and one (1) is shared. All the six (6) bedrooms were toured and appear to be clean and properly furnished. LPAs observed additional bedding and linens sufficient for all of the residents. Bathrooms: There are four (4) bathrooms which of three (3) are designated for resident use. LPA observed all bathrooms to have grab bars and non-skid mats. The hot water was tested and measured at 117.3 F.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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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 #3
FACILITY NUMBER: 197608084
VISIT DATE: 04/04/2022
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Garage: The staff bedroom leads into an attached garage. The staff bedroom is maintained locked and inaccessible to residents. Garage is used for additional storage and laundry area. Cleaning supplies are kept 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. The facility has a swimming pool that is locked and inaccessible to residents.

No deficiencies cited. Exit interview conducted. Report signed and delivered.

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

DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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