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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610420
Report Date: 09/08/2025
Date Signed: 09/08/2025 01:13:14 PM

Document Has Been Signed on 09/08/2025 01:13 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:SWEET HOME SENIOR LIVING 4FACILITY NUMBER:
197610420
ADMINISTRATOR/
DIRECTOR:		SPRY, NAIRAFACILITY TYPE:
740
ADDRESS:17259 BALLINGER STTELEPHONE:
(818) 419-5989
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 3DATE:
09/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Marine Bekyan, Coordinating ManagerTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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On 09/08/2025 at 9:30AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced, Annual Inspection and met with Marine Nazaryan, Caregiver. Marine Bekyan, Coordinating Manager arrived shortly after they were called. LPA asked for the census, staff and resident files.

The physical plant was toured inside and out at 10:25 am.

Living/Dining Room Area: LPA Saucedo observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 80 degrees Fahrenheit with a large television. There are several televisions and furniture for staff and residents for seating. They have two (2) fireplaces that have a covering, inaccessible to the residents. There also have a land-line telephone.

Bedrooms/Bathrooms: There are six (6) bedrooms. All six (6) bedrooms are used for residents. There are four (4) bathrooms. One (1) of the bedrooms has a private bathroom. In the hallway, there are closets that have extra linen. LPA observed the bedrooms to have bedding sheets, pillowcase, blankets, nightstands, televisions, and sufficient lighting for each of the resident’s room. The hot water temperatures were measured within regulations of 112 degrees. The showers have non-slip bathmats and grab bars.

There is also a signal system in the facility. There are two (2) fire extinguishers fully charged and are dated September 2025. One (1) is located in the kitchen area and one (1) is located in the garage.

Medications were kept in a locked drawer on your left-hand side of the kitchen. All medications were properly labeled and inaccessible to residents. The first aid kit is kept in this same closet.

LIC809C-continued

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SWEET HOME SENIOR LIVING 4
FACILITY NUMBER: 197610420
VISIT DATE: 09/08/2025
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Kitchen Area: LPA inspected the kitchen area. There is one (1) refrigerator which was clean and in good operation in this area. LPA observed sufficient supply of seven (7) day non-perishable and perishable foods in the cabinets. The knives/sharps were locked and inaccessible to the residents on your left-hand side.

Garage: The washer and dryer are kept in the garage area. The garage area has another refrigerator and fire extinguisher. There is also incontinence, mattresses in this area.

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility has a pool that is gated and locked and inaccessible to the residents.

The carbon monoxide and the smoke detector were tested, and they were operable, interconnected.

Administration: The Liability Insurance was reviewed and will be renewed on 11/08/2025. There are several Covid 19 signs on the wall, YES, Emergency Disaster Plan, Personal Rights, Theft and Loss Policy. The last fire drill that was conducted was on 09/01/25.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the Marine Bekyan, Coordinating Manager.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Gina Saucedo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
LIC809 (FAS) - (06/04)
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