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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610557
Report Date: 04/30/2024
Date Signed: 04/30/2024 11:24:56 AM

Document Has Been Signed on 04/30/2024 11:24 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WYNNE HOMEFACILITY NUMBER:
197610557
ADMINISTRATOR/
DIRECTOR:		ASATRYAN, LUSINEFACILITY TYPE:
735
ADDRESS:6610 WYNNE AVE.TELEPHONE:
(747) 283-7941
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 0DATE:
04/30/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Lusine Astryan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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At 9:15 am, Licensing Program Analyst (LPA), Huma Rahimi conducted an announced Pre-Licensing visit to the above facility and met with Administrator Lusine Astryan. LPA conducted an entrance interview with the Administrator. At the time of this visit LPA did not observe any residents present in the facility. Fire Clearance dated 01/17/2024 and received for four (4) Ambulatory clients. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. The facility is a single-story building. LPA toured the physical plant inside and outside and observed the following:

KITCHEN: At 9:30 LPA toured the kitchen. The kitchen area is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPA observed adequate supplies of nonperishable food and dining ware to accommodate a maximum capacity of four (4). All knives and sharps are observed to be locked in lock box in the kitchen under the sink along with other chemicals and toxins inaccessible to clients. At 9:35 AM, LPA observed a full Fire Extinguisher hanging next to the kitchen wall, and was last purchased on 12/27/2023.

BEDROOMS: There are four (4) bedrooms of which three (3) bedrooms are for clients use and one (1) designated for staff which will be locked and inaccessible to clients. Bedroom # one (1) and bedroom # three (3) are private and bedroom # two (2) is shared. LPA observed all bedrooms properly furnished with beds, dressers and required bedding, chest drawer, and linen. The bedrooms have sufficient closet space and have sufficient lighting. Facility will have a live-in staff at the facility. LPA did not observe any obstruction or hazard.



Continue on LIC 809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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: WYNNE HOME
FACILITY NUMBER: 197610557
VISIT DATE: 04/30/2024
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BATHROOMS: At 9:40 AM, LPA observed two (2) bathrooms. One (1) for clients use and one (1) for staff use only. Both bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed to have an appropriate non-skid mat. At 9:47 AM, the water temperature was noted at 116.1°.

COMMON AREAS: LPA observed all common areas to be clean in good repair. The facility maintains a comfortable temperature at 69°F. The living room and dinning rooms were properly furnished. No obstructions and or tripping hazards throughout the facility.



MEDICATION: The medication and facility staff/resident files will be kept in a locked cabinet located in the living room in the corner.

LAUNDRY ROOM: The laundry room is located in the hallway across to the client’s bathroom. The laundry room will only contain the washer and dryer and laundry detergents will be locked in the kitchen under the sink with other toxins and will be inaccessible to clients. The washer/dryer are brand new and are in good repair.

SURROUNDING GROUNDS: The facility has a backyard and has sufficient space. LPA observe appropriate outdoor furniture, and a covered shaded area for clients. LPA observed a locked storage area where extra laundry detergents, extra water bottles, and other extra items will be kept. There is no swimming pool or any bodies of water at the facility.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 9:55 AM, they were tested and observed to be operational.

Component III was conducted with the Administrator.

Pursuant to Title 22, the facility is compliant to regulation, and ready for licensure. This report will be forwarded to the Centralized Application Bureau (CAB). The applicant will be notified by the CAB Analyst when their license is approved.



Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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