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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609659
Report Date: 09/27/2023
Date Signed: 09/27/2023 02:24:28 PM

Document Has Been Signed on 09/27/2023 02:24 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SWEET HOME SENIOR LIVING 2FACILITY NUMBER:
197609659
ADMINISTRATOR:SRMIKYAN, LUSINEFACILITY TYPE:
740
ADDRESS:6460 VARNA AVETELEPHONE:
(818) 616-4103
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 5DATE:
09/27/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Lusine Srmikyan, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 07/29/2023. At 12:05 p.m., the LPA met with the Coordinating Manager and the Administrator.

At 12:06 p.m., the LPA conducted a brief physical plant tour to ensure there are no health and safety hazards.

RECORD REVIEW: At 12:18 p.m., the LPA reviewed resident records for five (5) out of five (5) residents. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. All files were in order.

At 1:20 p.m., the LPA conducted a review of medication and medication documentation with the Administrator for four (4) residents and observed that all medications were properly documented.

Copy of valid liability insurance and Facility Emergency Plan was provided to the LPA during the visit.

No deficiencies cited at this time. Exit interview conducted. A copy of the report of provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
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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