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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607601
Report Date: 11/09/2022
Date Signed: 11/09/2022 03:15:51 PM


Document Has Been Signed on 11/09/2022 03:15 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:SENIOR'S NESTFACILITY NUMBER:
197607601
ADMINISTRATOR:HALINA WROBELFACILITY TYPE:
740
ADDRESS:25821 FORSYTHE WAYTELEPHONE:
(661) 287-3144
CITY:STEVENSON RANCHSTATE: CAZIP CODE:
91381
CAPACITY:6CENSUS: 5DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Halina WrobelTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with the Administrator, Halina Wrobel, for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 1:50pm and the following was noted:
There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE stored in the office. The facility has a total of seven (07) bedrooms, of which three (03) are used for residents and three (03) bathrooms, of which one (01) is used for residents. The facility is fire cleared for six (06) non-ambulatory residents. The facility is currently occupying five (05) non-ambulatory residents and two (02) are under hospice care. The facility has outdoor furniture, with a covered shaded area for residents. The facility does not have a swimming pool/body of water. The garage is being used for storage. Laundry detergents, cleaning agents and other toxins are stored in the laundry room. Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.
Knives and sharps are observed to be locked in a drawer inaccessible to residents. Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 72°F. The smoke detectors are hardwired, interconnected and observed to be operational. Carbon monoxide detectors are operational as well. Fire extinguishers are located in the hallway and kitchen, observed to be full and last purchased on 10/12/2022.
(continued on LIC 809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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 2


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: SENIOR'S NEST
FACILITY NUMBER: 197607601
VISIT DATE: 11/09/2022
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Staff rooms were observed to be locked and located upstairs. No medications are observed in the staff room. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 117.4°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets upstairs and in each of the resident’s rooms. LPA observed medication to be locked and inaccessible to residents, located in the office. First aid kit observed to be stored in the downstairs bathroom.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
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