197610320-4-8-2026-31-AS-MAGN-DSXVKF-20260408163016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610320
Report Date: 04/08/2026
Date Signed: 04/08/2026 04:30:39 PM

Document Has Been Signed on 04/08/2026 04:30 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:	KAPIKYAN, ANDRANIK		FACILITY TYPE:	740
ADDRESS:	19733 HEMMINGWAY ST		TELEPHONE:	(818) 434-9916
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY: 6		CENSUS: 5	DATE:	04/08/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:27 PM
MET WITH:	Andranik Kapikyan- Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

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In conjunction to the complaint 31-AS-20260330151508, Licensing Program Analyst (LPA) Mariana Agban conducted a Case Management visit. During the course of the investigation, LPA made the following observations:

· Resident #1 (R1): There was no documentation of insulin administration recorded in the Centrally Stored Medication and Destruction Record (LIC 622). Additionally, the Administrator did not ensure that the insulin container matched the medication label, including verification of the appropriate quantity.

· Resident #2 (R2): The Centrally Stored Medication and Destruction Record (LIC 622) was not up to date. Records reflected a fill date of 03/03/26; however, R2 received a new medication with a fill date of 03/30/26.

· Resident #3 (R3): The Administrator reported that R3’s medication had run out and that the facility is currently awaiting a refill.

· Resident #4 (R4): The Administrator reported that R4’s medication had run out and that the facility is currently awaiting a refill.

· Resident #5 (R5): No medications were observed on site. The Administrator stated that R5 has been refusing to attend medical appointments and obtain medications. The LPA did not observe any medication refusal documentation at the time of the visit. The Administrator stated that the documentation would be provided promptly.

LPA reviewed the facility’s Plan of Operation p.4, which states:
"This facility will assist residents with their medications. This includes centrally storing medications, assisting residents with taking medications as prescribed, reordering medications as necessary, documenting refusals, and notifying the physician and family/responsible party."

Based on observations, record review, and interviews conducted, the facility did not follow its Plan of Operation.

An exit interview was conducted. Citations were issued. Appeal rights were provided, and a copy of this report was reviewed with and signed by the Administrator Designee

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Mariana Agban
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026

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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Document Has Been Signed on 04/08/2026 04:30 PM - It Cannot Be Edited

Created By: Mariana Agban On 04/08/2026 at 03:32 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WINNETKA HOME CARE	FACILITY NUMBER: 197610320
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/15/2026 Section Cited CCR 87208(a)	1 2 3 4 5 6 7	Plan of Operations: The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The administrator will audit insulin for R1 and update LIC 622 for R2 as well. For R3 and R4, the Administrator will provide proof of refilled medications. For R5, the Administrator will provide the resident refusal medication form by the POC date.
	8 9 10 11 12 13 14	Based on observations, record review, and interviews conducted, the facility did not follow its Plan of Operation. R1's had no documentation of insulin administration. R2's LIC 622 is not updated. R3 and R4 had no refill medication. R5 had documention of medication refusal. This poses a potential health, safety or personal rights risk to residents in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:

	Mariana Agban
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026

LIC809 (FAS) - (06/04)

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