197610320-10-29-2023-31-AS-RVAA-CX3VSW-20231029164214

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610320
Report Date: 10/29/2023
Date Signed: 10/29/2023 04:42:22 PM

Document Has Been Signed on 10/29/2023 04:42 PM - 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 HOME CARE		FACILITY NUMBER:	197610320
ADMINISTRATOR:	HARUTUNYAN, ALLA		FACILITY TYPE:	740
ADDRESS:	19733 HEMMINGWAY ST		TELEPHONE:	8184349916
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 5	DATE:	10/29/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Alla Harutunyan, Administrator		TIME COMPLETED:	04:50 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	A Required One (1) year - Annual visit was conducted today by Licensing Program Analyst (LPA) Rosaura Valenzuela. LPA met with Administrator Alla Harutunyan and explained the purpose of the visit. LPA observed that five (05) residents were at the facility during visit. A tour of the physical plant was conducted at 12:30 PM and the following was noted: The front main door is the only entrance being utilized at the facility. The facility is a single story home with four (5) client bedrooms and two (2) bathrooms. There is no body water in the facility. Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels. Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at a range of 105.6°F to 120.0°F and within the required range. Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit. Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition. Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked inside the garage. Knives and sharps are kept locked underneath the kitchen sink. Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable. Temperature of facility wall thermostat is set at 73.0°F and observed to be within the required range. Fire extinguishers. The facility has two (02) fire extinguishers which were serviced on 06/23. Carbon monoxide and smoke alarms are hardwired and interconnected, tested and observed to be operable.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WINNETKA HOME CARE	FACILITY NUMBER: 197610320
	VISIT DATE: 10/29/2023

NARRATIVE

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Garage is attached to the house and toxic chemicals are stored there. The laundry room is also located there. Garage was observed to be locked and inaccessible to residents. The garage is also used as a storage for PPE and other supplies.

Client records were reviewed for current Needs and Service plans, physician report, admission agreements, etc. Client records appeared to be complete and current.

Medication was observed to be inaccessible to residents and stored in a secured cabinet located in the kitchen. There is a complete First Aid kit.

Staff records were reviewed. Staff present records were observed to be current and updated.

No health and safety issues were noted at the time of this visit.

Exit interview conducted and a copy of this report was given.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2023

LIC809 (FAS) - (06/04)

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