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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610225
Report Date: 02/08/2022
Date Signed: 02/08/2022 06:24:36 PM

Document Has Been Signed on 02/08/2022 06:24 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:A SWEET HOME CAREFACILITY NUMBER:
197610225
ADMINISTRATOR:KARAPETYAN, DIANAFACILITY TYPE:
740
ADDRESS:25141 HIGHSPRING AVE.TELEPHONE:
(818) 606-8707
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY: 6CENSUS: 6DATE:
02/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Diana KarapetyanTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Abeye Duguma conducted an announced Pre-licensing visit at 02:00 PM and met with the candidate Diana Karapetyan. This is a change of ownership application from Majestic Senior Living Inc. (LIC 197609313) to A SWEET HOME CARE (LIC 197610230). There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign-in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. LPA observed three (03) staff members and all were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE stored in the garage. The facility has a total of four (04) bedrooms of which three (03) are for residents and one (01) is for staff. The facility has two (02) bathrooms for both residents and staff. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for hospice (06). The facility is currently occupying six (06) non-ambulatory residents of which two (02) is under hospice care. The facility has outdoor furniture with a covered shaded area for clients and visitors. The facility does not have a swimming pool/body of water. The garage is being used for laundry and storage. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the garage. Kitchen was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.

(continued on 809C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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: A SWEET HOME CARE
FACILITY NUMBER: 197610225
VISIT DATE: 02/08/2022
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Knives and sharps are observed to be locked in a drawer inaccessible to residents. Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located in the kitchen, observed to be full and last inspected on 09/10/2021. Staff rooms were observed to be locked and located near the dining area. No medications are observed in the staff room. The clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Clients have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 118.3°F. Towels and washcloths are not shared. There was enough clean linen available in the hallway cabinet. LPA observed medication to be locked and inaccessible to residents, located in the family room. There is a complete first aid kit located in the kitchen near the sliding door exit.

At the time of this visit the physical plant is meeting Title 22 requirements.

The Component III was completed with LPA Duguma on 02/08/2022.

No health and safety hazard were noted during this visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC809 (FAS) - (06/04)
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