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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610320
Report Date: 11/22/2024
Date Signed: 11/22/2024 06:25:01 PM

Document Has Been Signed on 11/22/2024 06:25 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WINNETKA HOME CAREFACILITY NUMBER:
197610320
ADMINISTRATOR/
DIRECTOR:		HARUTUNYAN, ALLAFACILITY TYPE:
740
ADDRESS:19733 HEMMINGWAY STTELEPHONE:
(818) 434-9916
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 6DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:18 PM
MET WITH:Alla Harutyunyan - AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
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Licensing Program Analyst (LPA) Gary Tan met with Administrator Alla Harutyunyan for a One (1) Year Required visit for this facility. LPA informed the Administrator the purpose of the visit.

There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted indoors. 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 visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

A tour of the physical plant was conducted with staff Leonisa Balsomo at 3:28 PM. The facility is a single storey building with four (4) bedrooms and two (2) bathrooms currently occupying five (5) residents. The facility is fire cleared for six (6) non-ambulatory residents, one (1) of which may be bedridden on Room 3. Hospice waiver for two (2) residents.

Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted:

Living and dining room furniture were also checked. The living room is neat and clean along with dining area. The facility maintains a comfortable temperature at 74°F. The smoke detectors are hardwired and interconnected and observed to be operational. The fire extinguishers were filled and last inspected on 06/21/24. There is a carbon monoxide detector installed at the facility. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WINNETKA HOME CARE
FACILITY NUMBER: 197610320
VISIT DATE: 11/22/2024
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The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. There is no body of water in the facility. The backyard has a twenty (20) footer trailer being used as miscellaneous storage. The garage was converted into an additional dwelling unit (ADU) and currently being used as office, staff bedroom, frozen food storage and laundry area. There is no access to the staff house from inside the facility. Laundry detergent and other cleaning agent is locked in the garage. There is no body of water in the facility.

Food Service/Kitchen area was sufficiently stocked with 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. Knives and sharps are observed to be kept in a locked drawer in the kitchen.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 115.9°F to 118.5°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet.

Medications: LPA observed medication are kept in a medication cart located in the kitchen. The cart was observed to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. First aids kits have complete tools and supplies.

Client records: Client records are reviewed and appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff record. Staff records appeared to be complete and updated.

Disaster drill was last conducted on 11/01/2024. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
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