197609099-3-22-2021-31-AS-PSHN-BZCSU3-20210322141028

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609099
Report Date: 03/22/2021
Date Signed: 03/22/2021 02:10:47 PM

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:	NESTLE PLACE SENIOR CARE FACILITY		FACILITY NUMBER:	197609099
ADMINISTRATOR:	MODYAN, ANNA		FACILITY TYPE:	740
ADDRESS:	6840 NESTLE AVE		TELEPHONE:	(818) 578-8658
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 0	DATE:	03/22/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Anna Modyan/ Administrator		TIME COMPLETED:	02:20 PM

NARRATIVE

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A case management closure visit was conducted on this day by Licensing Program Analyst (LPA) Patrick Shanahan at 1:530 pm. LPA Shanahan conducted a FaceTime visit with Anna Modyan. LPA Shanahan stated the purpose of this visit is to confirm and document the closure of this facility and ensure all residents have been relocated. Due to the situation surrounding the Corona virus Disease 2019 (COVID-19), and to implement mitigation measures, today’s case management closure visit was conducted as a FaceTime visit.

The facility closure was initiated by the licensee. The licensee notified Community Care Licensing Division (CCLD), that the licensee intends to close the facility.

Anna Modyan began the tour by walking through Rooms 1 through 4. LPA Shanahan observed there were no residents within the rooms. LPA Shanahan then observed the bathrooms and observed it was empty. Mrs. Modyan then passed through the living room and the activity room and indicated that there were no more residents. LPA Shanahan was able to inspect the backyard and the garage. LPA Shanahan observed there were several items stored in the garage but there were no residents in the garage. Mrs. Modyan then proceeded to the backyard and showed LPA Shanahan that the backyard storage room only contained stored items for the facility.

The visual tour concluded at 2 pm. LPA Shanahan stated the 809 will be sent to the Administrator for signature and the signed form will need to be sent to LPA Shanahan via email.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick Shanahan	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

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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