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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610599
Report Date: 09/14/2025
Date Signed: 09/14/2025 11:49:53 AM

Document Has Been Signed on 09/14/2025 11:49 AM - 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: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:
09/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Serge Petrosian - House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jose Tan conducted an Annual Required inspection of this facility today. LPA met with the House manager, Serge Petrosian and explained the reason for the visit. Per the house manager, they never had any client since opening and currently applying for vendorization at the North Los Angeles Regional Center (NLARC) Level III RCFE.

A tour of the physical plant was conducted at 9:39 AM and the following was noted:

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 Infection Control and Mitigation plan.

The facility is fire cleared for six (6) non-ambulatory residents one (1) for may be bedridden in room #1. Facility was also approved for a Hospice waiver for six (6) residents. The facility is a single storey building and has four (4) bedrooms and two (2) bathrooms currently with no residents. The facility dual smoke/carbon monoxide alarm system are hard wired and interconnected, tested and observed to be operational. The fire extinguisher is located by the dining area and was observed to be fully charged and last purchased on 09/14/25.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility and properly stored. Knives were stored in a locked drawer .

Bedrooms: All four resident rooms were properly furnished with appropriate beddings and linens with sufficient lighting. (continued on LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2025
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WYANDOTTE VILLA
FACILITY NUMBER: 197610599
VISIT DATE: 09/14/2025
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(continued from LIC 809)

Bathrooms: The bathrooms for the residents were observed to have grab bars, non-skid mats and properly supplied with hygiene products. Hot water temperature was measured at a range of 115.2°F to 117.5°F. LPA did not observe any toxins or cleaning supplies in any of the bathrooms during the day's visit.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The dining room area and table is large enough to accommodate up to six (6) residents. The auditory alarms on all exit doors were on and functional at the time of the visit. The fireplace is non-operational and there was a glass and screen door in place.

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. The laundry area is located in bedroom hallway and was locked at the time of the visit. Detergents and cleaning supplies are kept in a bedroom hallway cabinet, locked and inaccessible.

Garage: There is no garage at the facility only drive way. This driveway leads to two (2) additional dwelling unit (ADU) with a separate address, the ADUs gate was locked and has no access from the facility. Laundry Area: LPA observed the laundry area is located by the living room. Laundry detergents, cleaning agents and other toxins were kept in the locked cabinet in the bedroom hallway.

Medications: Medications will be kept in a locked cabinet in the bedroom hallway. There are two (2) complete first aid kits located in the medication closet.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit.

Exit Interview Conducted and a Copy of the Report Issued.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Jose Gary Tan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2025
LIC809 (FAS) - (06/04)
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