197610514-3-21-2025-31-AS-MSPH-DEYSE7-20250321134812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610514
Report Date: 03/21/2025
Date Signed: 03/21/2025 01:48:37 PM

Document Has Been Signed on 03/21/2025 01:48 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 HOME		FACILITY NUMBER:	197610514
ADMINISTRATOR/ DIRECTOR:	SISAKYAN, BABKEN		FACILITY TYPE:	735
ADDRESS:	3728 E AVE Q-12		TELEPHONE:	(818) 219-3131
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93550
CAPACITY: 4		CENSUS: 2	DATE:	03/21/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Babken Sisakyan		TIME VISIT/ INSPECTION COMPLETED:	12:00 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) Spaeth conducted an unannounced annual inspection and was greeted by a staff member. LPA Spaeth spoke to the Licensee, Babken Sisakyan by phone and explained the purpose of the visit. The facility is licensed for four ambulatory clients. The Administrator confirmed there are two clients living in the home and were attending an adult day program. The Licensee, Administrator, Jacqueline Page, and Administrator Designee, Vashan Bobney arrive to the facility. Today’s visit consisted of LPA touring the physical plant inside & outside from 9:45 am until 10:00 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 are 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 are 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. Continued on 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NEBULA HOME	FACILITY NUMBER: 197610514
	VISIT DATE: 03/21/2025

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

Bathrooms- There are two bathrooms which contained hand soap, paper towels, and trash can.

Water Temperature – The water temperature was recorded at 10:00 am and was 119 degrees F.

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

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

The smoke and carbon monoxide detectors were tested at 9:50 am and were operable. The facility was clean and appears to be in good repair.

LPA Spaeth reviewed the client files at 10:05 am until 10:25 am. LPA Spaeth reviewed the staff files at 10:35 am until 11:00 am. LPA reviewed a client's medication at 11:19 am until 11:30 am.

There are no deficiencies to report at this time. Exit interview conducted and a copy of the report given..

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2025

LIC809 (FAS) - (06/04)

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