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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610320
Report Date: 11/22/2022
Date Signed: 11/22/2022 11:12:20 AM

Document Has Been Signed on 11/22/2022 11:12 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 CAREFACILITY NUMBER:
197610320
ADMINISTRATOR:HARUTUNYAN, ALLAFACILITY TYPE:
740
ADDRESS:19733 HEMMINGWAY STTELEPHONE:
(818) 434-9916
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 5DATE:
11/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Alla HarutunyanTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection with the facility administrator, Alla Harutunyan. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on July 15, 2022 for a Change in Ownership. A fire clearance was approved on August 4, 2022 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The applicant is also requesting a hospice waiver to retain two (2) residents. The smoke alarms are battery operated and interconnected. There is a battery operated carbon monoxide detector installed in the hallway by resident rooms. The facility has two fire extinguishers, that were charged on 2/1/2022. One fire extinguisher is located in kitchen, and the other in the garage converted storage and staff break area.

A tour of the physical plant was initiated at approximately 9:40am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. The There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives were observed locked in a kitchen drawer.

BEDROOMS: There are four (4) bedrooms designated for client use. Bedroom #1 and #3 are cleared to be shared rooms. Per Fire Safety Inspection Request (STD 850), bedroom #3 has a bedridden fire clearance. Bedrooms #2 and #4 are private rooms. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has two (2) bathrooms. Bedroom #3 has it's own bathroom. The other bathroom is located in the hallway, between bedroom #2 and #3. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 109 degrees.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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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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: 197610320
VISIT DATE: 11/22/2022
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COMMON AREAS: These included the living room which was equipped with living room furniture, a television, tables and chairs. There is a fireplace with a screen and a glass slide. It is non-operational, with the key stored and inaccessible to residents. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards. Cleaning supplies are stored and locked in the garage converted storage area. Additional non-perishable canned food supply for seven days is also stored there.

LAUNDRY ROOM: The laundry room is located in the garage converted storage area. This area is observed with a combination lock making it inaccessible for residents to enter.

MEDICATIONS: The medication cart will be maintained in the kitchen. It has a locking mechanism. The key is carried by staff at all times. It has a locking mechanism.

Staff/Resident Records: Staff and resident records are maintained in a cabinet next to the medication cart, located in the kitchen.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. Both side gates were checked to insure exit and passageways were clear of obstruction.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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