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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609875
Report Date: 07/26/2021
Date Signed: 07/26/2021 03:00:55 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: 5DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rory BelsomoTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced annual required visit. LPA met with facility staff and explained the reason for this visit. Adminstrator representative was called and made aware of the visit.
A tour of the physical plant was conducted with staff upon entry. the LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The following was noted: Facility is a single story residence and consists of four (4) bedrooms and two (2) bathrooms. Facility does not have a designated staff room. Fire Clearance was approved on 7/25/19 for six (6) non-ambulatory residents, one of which may be bedridden in room #3. Facility has dementia residents. All exit signal alarms were tested and function properly. Smoke detectors are hard wired through out the facility. Smoke detectors and Carbon Monoxide detector were tested and functioned properly during time of visit. Fire extinguisher was observed to be fully charged.
Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a locked cabinet under the sink. Properly labeled medications are locked in a medication cart in the kitchen.
Bedrooms: The resident bedrooms were properly furnished with at least one chair, a dresser/night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.
Bathrooms: LPA observed both bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars or commodes and non-skid mats in all bathrooms. Residents have sufficient amount of supplies for personal hygiene. Hot water temperature was measured at 115 degrees Fahrenheit.
Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. No deficiencies cited.
Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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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