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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609875
Report Date: 04/23/2021
Date Signed: 04/23/2021 05:13:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WINNETKA HOME CAREFACILITY NUMBER:
197609875
ADMINISTRATOR:CHILIAN, HRIPSIMEFACILITY TYPE:
740
ADDRESS:19733 HEMMINGWAY STREETTELEPHONE:
(818) 429-0797
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: DATE:
04/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Hripsimi ChilianTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst conducted a case management virtually due to the corona-virus pandemic. The purpose of this visit was to address non-submittal of the Mitigation Plan Report. The LPA spoke with the administrator Hripsimi Chilian regarding this issue.

PIN 20-48-ASC announced the requirement for licensees of Adult and Senior Care (ASC) facilities to submit a plan for Epidemic Outbreaks, specific to COVID-19 (“Mitigation Plan Report”) by January 24, 2021. The PIN advised licensees that ‘Due to the global COVID-19 pandemic, the California Department of Social Services is requiring all licensees of ASC facilities to submit a Mitigation Plan Report to address epidemic outbreaks or communicable diseases specific to COVID-19 by January 24, 2021 pursuant to the following sections of the California Code of Regulations (CCR), Title 22, Section 80061 (a). The Mitigation Plan report has not been provided to the Woodland Hills Regional Office as required.

Deficiencies cited. The LPA conducted an exit interview with staff and discussed a plan of action. A copy of this report was provided via email.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WINNETKA HOME CARE
FACILITY NUMBER: 197609875
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2021
Section Cited

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Reporting Requirements- Each licensee shall furnish to the licensing agency such reports as the Department may require,
This requirement was not met as evidenced by
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The licensee did not ensure that this regulation was met when the Department required the facility to submit a mitigation plan by 01/24/2021 through notification to licensees on PIN 20-48-ASC that was issued 12/24/2020. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2021
LIC809 (FAS) - (06/04)
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