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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610599
Report Date: 08/01/2024
Date Signed: 08/01/2024 01:02:37 PM

Document Has Been Signed on 08/01/2024 01:02 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:WYANDOTTE VILLAFACILITY NUMBER:
197610599
ADMINISTRATOR/
DIRECTOR:		PETROSIAN, RAFAELFACILITY TYPE:
740
ADDRESS:11120 WYANDOTTE STTELEPHONE:
(818) 480-2844
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 6CENSUS: 0DATE:
08/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:29 AM
MET WITH:Rafael Petrosian, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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At 10:30am Licensing Program Analysts (LPA) Leizl de la Cerra conducted an announced Pre-Licensing Inspection to the above facility and met with Rafael Petrosian, Administrator and co-administrator, Margarit Sarkisyan. The LPA will inspect the facility to ensure that the facility is in compliance with the rules and regulations under California Code of Regulations, Title 22, Division 6.

Fire Clearance was approved on 06/04/2024 for a maximum capacity of six (6) residents, of which five (5) are for non-ambulatory and one (1) for a bedridden resident in room #1. Facility was also approved for a Hospice waiver for six (6) residents on June 05, 2024. The facility is a single-story building. At 10:45am, with the assistance of the Licensee, LPA conducted a facility tour of both the inside and outside premises and observed the following:

KITCHEN: The kitchen is equipped with a refrigerator, microwave oven and sink. LPA observed adequate supplies of nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.
BEDROOMS: There are four (4) bedrooms designated for client use. Bedroom #1 is cleared for one (1) bedridden. . All bedrooms are furnished with beds, night stands, chair, flashlights and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting.
Extra bed linens and towels are stored in a closet in the bedroom hallway.
BATHROOMS: LPA observed two (2) bathrooms that are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured between 110°- 112°F. observed the appropriate grab bars and have non-skid mats.

Continued to LIC809-C
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WYANDOTTE VILLA
FACILITY NUMBER: 197610599
VISIT DATE: 08/01/2024
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COMMON AREAS: The facility maintains a comfortable temperature at 73°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the common area.

SURROUNDING GROUNDS: LPA observed the front area of the facility as a sufficient yard space fro residents to use. Appropriate outdoor furniture, with a covered shaded area is available for residents.


LPA observe the garage is separate from the house and is located at the back area. The garage is locked and will be inaccessible to residents in care.

LAUNDRY AREA: LPA observed laundry area located by the common area. The washer/dryer appear to be in good condition.

Cleaning solutions, laundry detergents and other hazardous cleaning materials are kept inaccessible in a locked cabinet located in the bedroom hallway.
The medications will be kept in locked cabinet in the bedroom hallway. inaccessible to residents in care. The first-aid kit is complete.
There is two drawer locked cabinet and a 4 drawer locked cabinet which will contain resident files and staff records located in the common area.
The facility smoke alarm system is hard wired and interconnected. The fire extinguisher is located near the dining area and was observed to be fully charged and was last purchased on 07/31/24. The facility uses a dual Carbon Monoxide/Smoke alarm detectors all over the common areas of the facility. Alarms were tested and observed to be operational.

Component III Orientation was conducted with the administrator/applicant during the visit.
LPA de la Cerra will notify the Centralized Applications Bureau (CAB) Analyst of the completed Pre-Licensing inspection. The CAB Analyst will notify applicant when license is approved.
Exit interview was conducted and a copy of the signed report has been emailed to the applicant.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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