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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610557
Report Date: 04/03/2025
Date Signed: 04/03/2025 10:29:36 AM

Document Has Been Signed on 04/03/2025 10:29 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:
04/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Lusine Astryan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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At 9:25 am, Licensing Program Analyst (LPA), Huma Rahimi conducted an unannounced Annual Inspection visit to the above facility. LPA observed that the main entrance is locked. LPA contacted the Administrator Lusine Astryan via telephone and explained the reason for the visit. The Administrator arrived a the facility at 10:00 AM.

LPA conducted an entrance interview with the Administrator. At the time of this visit LPA did not observe any clients present in the facility.

KITCHEN: At 10:05 AM 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 10:07 AM, LPA observed a full Fire Extinguisher hanging next to the kitchen wall, and was last purchased on 03/06/2025.

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
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/03/2025
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BATHROOMS: At 10:10 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 10:15 AM, the water temperature was noted at 109.9°.

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: LPA observed that 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 only contains the washer and dryer and laundry detergents are 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 10:20 AM, they were tested and observed to be operational.

LPA did not review any records for staff and clients due to the zero (0) census of the clients. Facility do not have any hired staff yet.


Administrative: LPA collected Certificate of Liability Insurance.

No deficiency issued during today’s visit.

Exit interview conducted and copy of this report signed and delivered.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC809 (FAS) - (06/04)
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