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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610784
Report Date: 07/02/2025
Date Signed: 07/02/2025 11:26:54 AM

Document Has Been Signed on 07/02/2025 11:26 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WINNETKA ASSISTED LIVINGFACILITY NUMBER:
197610784
ADMINISTRATOR/
DIRECTOR:		GASPARYAN, ANNAFACILITY TYPE:
740
ADDRESS:20152 ACRE STTELEPHONE:
(818) 213-4074
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 0DATE:
07/02/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:52 AM
MET WITH:Anna Gasparyan - AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 7/2/25 at 9:30am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a Pre-Licensing Inspection with the facility Administrator Anna Gasparyan. Upon arrival, LPA introduced herself by showing her department badge. This is a single-story house which will be operating as Residential Care Facility for Elderly (RCFE). A fire clearance was approved on April 8th, 2025, for six (6) Non-Ambulatory residents of which one (1) may be Bedridden for bedroom #3. Facility also received Hospice approval for five (5) residents. The smoke alarms and carbon monoxide detectors are hard wired and inter-connected, they were tested and are operational. The facility has one (1) fire extinguisher that was purchased on 3/21/2025 and is located on the kitchen wall.

A tour of the physical plant was initiated at approximately 10:00am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave oven and sink. LPA observed adequate supplies of emergency and nonperishable food properly stored inside the kitchen cabinets. Perishable food items are not required at this time as there are no residents in the facility. Licensee will supply sufficient amount of perishable food upon arrival of the residents. Complete dining ware was available to accommodate a maximum capacity of six (6) residents. Knives and other sharps were observed locked inside the kitchen cabinet and chemicals observed stored inside locked cabinet located in the laundry room.

BEDROOMS: The facility has four (4) bedrooms, and all bedrooms are designated for residents' use. All residents' bedrooms observed to be nicely furnished with beds, night stands, lamps, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and a closet space. Additional linen is available inside each bedroom’s closet.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WINNETKA ASSISTED LIVING
FACILITY NUMBER: 197610784
VISIT DATE: 07/02/2025
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BATHROOMS: The facility has two (2) bathrooms, both bathrooms are designated for residents’ and staff use. All bathrooms were observed to have the proper fixtures, grab bars, non-skid mats, trash cans with closed lids, paper towels and washing hands signs. The hot water delivered in the bathrooms measured at 10:15am to be at 115.7 degrees F.

COMMON AREAS: These includes living room and a dining room. The living room was equipped with new furniture, a television, and coffee table. The dining area has a dining table to accommodate six (6) residents. There were no visible immediate hazards. The facility has comfortable temperature which was measured at 10:45am to be at 73 degrees F. LPA observed various activity supplies nicely stored inside the activity stand and ready for residents' use.

LAUNDRY ROOM: The washer and dryer is located in a laundry area across from the kitchen. Laundry chemicals will be stored inside the separate storage area, which will always be locked and under supervision.

MEDICATIONS/ Client/Staff Files: Medications will be kept inside the locked commercial storage cabinet next to the kitchen area. First Aid and the new manual is also locked inside the same cabinet. LPA observed the First-aid has all proper items and is current. Files will be kept inside separate locked cabinet located in the office area next to the dining room.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. The backyard of the facility is properly fenced, has a patio and backyard furniture to accommodate six (6) residents.

GARAGE: The garage is currently being used as storage for facility equipment, supplies and water. Garage is attached to the facility, however, has no access from the house.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: WINNETKA ASSISTED LIVING
FACILITY NUMBER: 197610784
VISIT DATE: 07/02/2025
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LPA observed the facility is clean, safe and sanitary. All window screens were in good repair. Auditory signals were installed on all exit doors. All passageways were free of obstruction.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised.

An emergency exit plan/sketch along with other posting requirements were available and posted on the wall.

No deficiency cited on today’s visit.

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

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
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