197610320-8-6-2025-31-AS-PKHN-DKASLQ-20250806135844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610320
Report Date: 08/06/2025
Date Signed: 08/06/2025 02:00:49 PM

Document Has Been Signed on 08/06/2025 02:00 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:	WINNETKA HOME CARE		FACILITY NUMBER:	197610320
ADMINISTRATOR/ DIRECTOR:	HARUTUNYAN, ALLA		FACILITY TYPE:	740
ADDRESS:	19733 HEMMINGWAY ST		TELEPHONE:	(818) 434-9916
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY: 6		CENSUS: 5	DATE:	08/06/2025
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:05 PM
MET WITH:	Isaiah Phiri - Caregiver		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

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ON 8/6/2025 Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a Case Management visit at the above facility to verify that Resident #1 (R1) relocated to the facility on 8/5/2025, and to confirm that R1 is doing well following the transition. Upon arrival LPA met with the Caregiver Isaiah Phiri and explained the reason for the visit. Entrance interview conducted. Facility Co-Administrator Andranik Nick Kapikyan arrived shortly after.

At approximately 12:45pm LPA requested facility staff and clients’ rosters. During today’s visit, LPA conducted a physical plant tour at the facility to ensure health and safety of the residents are protected.

LPA requested to confirm R1’s identity and well-being. During the physical plant tour, LPA checked R1’s private room and observed R1 on wheelchair resting in their room. A brief interview was conducted with R1. R1 appeared alert and oriented to place and time. R1 expressed that the move was smooth and reported feeling comfortable in the new facility. No signs of distress were observed during the visit.

To confirm R1’s identity, LPA verified R1’s name and date of birth with both the resident and facility records. Based on LPA’s observation and brief interview, R1 appears to be adjusting well and had no concerns or complaints.

During today's visit LPA collected the following documents:

LIC500
LIC9020

No deficiencies were observed during this visit.

Exit interview conducted with the Administrator. A copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

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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