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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610514
Report Date: 03/21/2024
Date Signed: 08/08/2024 01:38:18 PM

Document Has Been Signed on 08/08/2024 01:38 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:NEBULA HOMEFACILITY NUMBER:
197610514
ADMINISTRATOR:SISAKYAN, BABKENFACILITY TYPE:
735
ADDRESS:3728 E AVE Q-12TELEPHONE:
(818) 219-3131
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 4CENSUS: 0DATE:
03/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Babken SisakyanTIME COMPLETED:
11:30 AM
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
On 3/21/2023 Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with the Licensee. This is a new application and a fire clearance dated 01/05/2024 was received for four (4) ambulatory clients. The facility phone number is 661-382-8634.

The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6. Component III was conducted with the applicant from 9:25 am until 10:10 am.

Today’s site visit consisted of LPA touring the physical plant inside & outside from 10:15 am until 10:50 am.

Living Room – The room contained a keyboard, dining room table, and dining room chairs.

Kitchen/Family room - The facility contained a seven-day supply of non-perishable food and a two-day supply of perishable foods. The knives were locked in a kitchen drawer. The cleaning solutions were locked underneath the kitchen sink. The medications and the first aid kit will be locked in a storage cabinet. A fire extinguisher is also located in the kitchen. Appliances in the kitchen appeared to be functional. The resident and staff files will be locked in a file cabinet located in the kitchen.

Backyard - The backyard contained a shaded area with comfortable seating. The side gate leading from the backyard to the front yard was not locked.

Bedrooms – There are four client rooms which contained bed, mattress, bed linens, chair, lamp and an armoire. The staff room was locked.

Continued - 809C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NEBULA HOME
FACILITY NUMBER: 197610514
VISIT DATE: 03/21/2024
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
Bathrooms- There are two bathrooms which contained hand soap, paper towels, and trash can.

Water Temperature – The water temperature was recorded at 10:30 am and was 117.1 degrees F.

Laundry Room – the laundry room was locked and contained the washer and dryer and PPE items.

Garage- Emergency food and additional linens were locked in the garage.

The smoke and carbon monoxide detectors were tested at 10:45 am and were operable. The facility was clean and appears to be in good repair.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2