197608595-7-23-2023-31-AS-TSMH-CU23HB-20230723181540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608595
Report Date: 07/23/2023
Date Signed: 07/23/2023 06:16:19 PM

Document Has Been Signed on 07/23/2023 06:16 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:	NEST, THE		FACILITY NUMBER:	197608595
ADMINISTRATOR:	MICHELLE WEISMAN		FACILITY TYPE:	740
ADDRESS:	4100 HAYVENHURST AVENUE		TELEPHONE:	(818) 990-6896
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY:	6	CENSUS: 6	DATE:	07/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Michelle Weisman		TIME COMPLETED:	06:19 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), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 9:20 am. LPA Smith was greeted by staff and disclosed the purpose of the visit. Staff contacted the administrator. LPA Smith spoke with the administrator and disclosed purpose of the visit. Administrator revealed will arrive shortly. LPA conducted a tour of the physical plant at approximately 11:20 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the kitchen, dining room area and living room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the five (5) residents currently residing there. Two (2) days of perishable and seven (7) days of nonperishable food observed. The freezer is stocked with meats and frozen vegetables. The resident medications are locked in cabinet in kitchen and observed to be locked an inaccessible to residents in care. The new first aid kit is stored in medication cabinet in kitchen. Sharps are locked in kitchen island drawer observed to be locked and inaccessible to residents. There are three (3) fire extinguishers: One (1) attached to wall in kitchen area and two (2) in laundry room. Fire extinguishers observed to be charged. Laundry room located in at end of first hallway by enclosed patio. The appliances observed to be in good repair. Toxins stored in cabinet in laundry and under kitchen sink. Toxins observed to be locked and inaccessible to residents. (Cont to 809C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NEST, THE	FACILITY NUMBER: 197608595
	VISIT DATE: 07/23/2023

NARRATIVE

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(Cont from 809)
The facility has a total of five (6) bedrooms and two (4) bathrooms. There are four (5) private bedrooms for residents and one (1) bedroom for staff.
The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens hall closet near bathroom.
The bathrooms have posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range measured:110.2- 113.2 degrees Fahrenheit.

Garage: Used to store PPEs, 2nd refrigerator food overflow and equipment.
Backyard has the following: Covered enclosed patio and Two (2) Patio tables observed to have adequate seating. Patio furniture observed to be in good repair. One (1) umbrella with table and one (1) umbrella stored in garage.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

At approximately 2:15 pm LPA reviewed (6) resident files. Resident files included but not limited to: Physicians reports, Preadmission appraisals, admission agreements, and personal rights. Three random staff files reviewed. Staff records reviewed had the appropriate personal records such as: Clearances, Employee Rights and First aid/CPR. Staff training's such as: Medication administration, administrator training, and certificates provided by Relias stored electronically verified by LPA. Administrator unable to print out all certificates due to computer issues.

No deficiencies cited.

Exit Interview Conducted / A Copy of the Report Issued

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2023

LIC809 (FAS) - (06/04)

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