<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610599
Report Date: 07/08/2026
Date Signed: 07/08/2026 05:59:03 PM

Document Has Been Signed on 07/08/2026 05:59 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:WYANDOTTE VILLAFACILITY NUMBER:
197610599
ADMINISTRATOR/
DIRECTOR:		SARKISYAN, MARGARITFACILITY TYPE:
740
ADDRESS:11120 WYANDOTTE STTELEPHONE:
(818) 480-2844
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 6CENSUS: 2DATE:
07/08/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:Administrator, Margarit Sarkisyan and Staff Raquel LopezTIME VISIT/
INSPECTION COMPLETED:
06:10 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
Licensing Program Analyst (LPA) Antonia Alvizar-Ettima for a case management visit to follow up with the incident report provided to the Licensing office on 06/26/26, informing that resident #1 (R1) became unresponsive during bathroom assistance. 911 was called and R1 was sent to the hospital.

During conversation, LPA was informed that R1 was admitted to the facility with a G-tube, R1 was unable to self-assist with a G-tube and was not a hospice resident. LPA made a follow-up contact and spoke with the staff and Administrator.

Information received revealed that R1 was admitted, retained and readmitted to the facility with prohibited health conditions that required higher level of care.

Therefore, LPA conducted follow up visit to get additional information regarding resident health conditions and other surrounding circumstances of the incident.

During the visit, at 3:00p.m., LPA toured the facility and at about 3:20p.m., LPA spoke with staff and R1. In addition, at approximately 3:45p.m., LPA reviewed R1’s file.

A review resident R#1 (R1) records conducted at revealed the information regarding R1’s home health care services and medical conditions.

LPA observed that R1 has a gastrostomy (G) tube. R1 stated that Staff #1 (S1) oversee their daily G-tube care, while the home health nurse visits once weekly. Record reviewed and staff interview indicated the resident is unable to independently perform all aspects of G-tube feeding and care.

During this visit LPA Alvizar-Ettima also discussed Title 22 regulations pertaining to restricted and prohibited

Cont. on LIC 809 - C

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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)
Page: 2 of 4
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: WYANDOTTE VILLA
FACILITY NUMBER: 197610599
VISIT DATE: 07/08/2026
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
26
27
28
29
30
31
32
Cont. from LIC 809

health conditions, exceptions and waivers and other pertinent information.

Based on observation, interviews and record review and interviews, the facility admitted, and retained a resident with a prohibited health condition, requiring higher level of care. This posse an immediate concern to Resident’s health and safety.

Therefore, under title 22, Division 6, Chapter 8, following deficiencies were cited and recorded on LIC809D. An immediate Civil penalty of $500.00 was issued at the time of this visit.

Exit interview was conducted, appeal rights were discussed and information on the report was disclosed to the Administrator.

Due to printing problems, the copy of the report will be e-mailed to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Antonia Alvizar-Ettima
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/08/2026 05:59 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 07/08/2026 at 04:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WYANDOTTE VILLA
FACILITY NUMBER: 197610599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2026
Section Cited
CCR
87615(a)(2)

1
2
3
4
5
6
7
87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes.
1
2
3
4
5
6
7
Administrator will seek higher level of care placement by POC due date. Administrator will submit written documentation indicating where resident was placed.
8
9
10
11
12
13
14
This requirement is not met as evidenced by. Operator continued to retain R1 requiring higher level of care. This possess an immediate health and safety risk for resident in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Antonia Alvizar-Ettima
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4