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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609847
Report Date: 07/11/2024
Date Signed: 07/11/2024 03:23:09 PM

Document Has Been Signed on 07/11/2024 03:23 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 1 FACILITYFACILITY NUMBER:
197609847
ADMINISTRATOR/
DIRECTOR:
KAREN BABAYANFACILITY TYPE:
740
ADDRESS:6458 VARNA AVENUETELEPHONE:
(818) 666-7601
CITY:VAN NUYSSTATE: CAZIP CODE:
91401
CAPACITY: 6CENSUS: 4DATE:
07/11/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Lusine Srmikyan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:23 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 01/27/2024. At 12:35 p.m., the LPA met with the Licensee and Coordinating Manager and explained the reason for the visit.

RECORD REVIEW: Starting at 12:44 p.m., the LPA reviewed resident records for four (4) out of four (4) residents. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. All files were in order. The LPA conducted a personnel file review for all staff regularly scheduled and reviewed for, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Personnel files reviewed were observed to be in compliance.

At 2:28 p.m., the LPA conducted a review of medication and medication documentation with the Licensee for four (4) residents. No errors observed during the medication review.

At 2:29 p.m., the LPA conducted a brief physical plant tour to ensure there are no health and safety hazards.

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: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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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