197609875-8-22-2022-31-AS-MCAA-CHJJZY-20220822073017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609875
Report Date: 08/19/2022
Date Signed: 08/22/2022 07:30:22 AM

Document Has Been Signed on 08/22/2022 07:30 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WINNETKA HOME CARE		FACILITY NUMBER:	197609875
ADMINISTRATOR:	CHILIAN, HRIPSIME		FACILITY TYPE:	740
ADDRESS:	19733 HEMMINGWAY STREET		TELEPHONE:	(818) 429-0797
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY: 6		CENSUS: 5	DATE:	08/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Allae Harutunyan, Rory Balsomo		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Evelin Rios and Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Allae Harutunyan and staff, Rory Balsomo and explained the reason for the visit. At 12:20am, with the assistance of staff, the LPAs took a tour of the physical plant. Required postings were observed at the entry area hallway and throughout the facility. The smoke alarms are battery operated and interconnected. There is a carbon monoxide detectors that functions properly located at the hallway. The fire extinguisher is located in the kitchen. The charge date is 5/10/2022. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in the medication cart located in the kitchen. Bedrooms: There were four (4) bedrooms designated for residents' use. Each bedrooms, in use by residents were were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 113 degrees Fahrenheit. Cleaning supplies are stored in the hallway closet. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

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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Document Has Been Signed on 08/22/2022 07:30 AM - It Cannot Be Edited

Created By: Michael Cava On 08/19/2022 at 01:11 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: 197609875
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: During the physical plant inspection, LPAs observed presctiption ointment medication, stored in the bathroom cabinet, accessible to residents in care.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2022
	Plan of Correction
1 2 3 4	During the inspection, staff removed and placed the medication in a locked hallway closet, located near the bathroom, making it inaccesible to the residents in care. No further corrections required.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Eva Miller

LICENSING EVALUATOR NAME:

Michael Cava

LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3

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
	VISIT DATE: 08/19/2022

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area and both side gates on each side of the facility was free of hazards. LPAs inspected the shed in the backyard which is used for storage. It is locked and kept unaccessible to the residents.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022

LIC809 (FAS) - (06/04)

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