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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610514
Report Date: 08/10/2026
Date Signed: 08/10/2026 01:31:35 PM

Document Has Been Signed on 08/10/2026 01:31 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:NEBULA HOMEFACILITY NUMBER:
197610514
ADMINISTRATOR/
DIRECTOR:		SISAKYAN, BABKENFACILITY TYPE:
735
ADDRESS:3728 E AVE Q-12TELEPHONE:
(818) 219-3131
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 4CENSUS: 3DATE:
08/10/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Vashan Bobney- DSPTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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On 8/10/2026 at approximately 12:20 PM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced Plan of Correction (POC) visit to the facility pertaining to the deficiencies cited during their annual inspection visit conducted on 8/01/2026.

Upon arrival, LPA observed Client 1 (C1) to be waiting outside of the front entrance of the facility. When LPA asked if anyone was home, C1 stated, “No, I am waiting for someone to return to let me in”. LPA proceeded to ring the doorbell to no response. LPA called the Administrator, Babken Sisakyan and stated the reason for their visit including that they along with C1 were waiting to gain entrance into the facility. Per the Administrator (S1), C1 was supposed to be at work and did not disclose they would be returning early to the facility. S1 informed LPA that staff would be arriving shortly to allow entrance into the facility. C1 correlated S1’s statement.

At 12:33 PM, the care staff was observed to arrive and allow entrance into the facility. LPA observed there to be no other clients or staff to be present inside at the time of entrance. LPA spoke with S1 who designed the care staff (S2) to assist with today’s visit and sign today’s report.

(Continue to LIC 809-C)

Troy Agard
Angelica Segovia
DATE: 08/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2026
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NEBULA HOME
FACILITY NUMBER: 197610514
VISIT DATE: 08/10/2026
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Regarding the citations:

On 8/01/2026, citation Type B was issued: 80068(a)(1) Admission Agreements: Based on record review, the licensee did not comply with the section cited above in C3 did not have documents from regional center or admission agreement at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.

POC: Administrator will obtain all required documents and send to LPA by POC due date.

On today’s visit, LPA received email confirmation from S1 documenting the signed Admission Agreement pertaining to C3. Additionally, LPA observed C3’s file to contain the required documentation such as but not limited to: LIC 405, LIC 601, LIC 602, LIC 603, LIC 605 A, LIC 613, LIC 625, Consent for Emergency Medical Treatment, LIC 9172. Deficiency cleared as of 8/10/2026.

On 8/01/2026, citation Type B was issued: 80069(b) Client Medical Assessments: Based on record review, the licensee did not comply with the section cited above in C3 did not have a physicians report which poses/posed a potential health, safety or personal rights risk to persons in care.

POC: Administrator will send 602 to LPA by POC due date.

On today’s visit, LPA received confirmation via email from S1 of C3’s completed LIC 602. Deficiency cleared as of 8/10/2026.

On 8/01/2026, citation Type A was issued: 80088(e)(1) Fixtures, Furniture, Equipment, and Supplies. Based on observation, the licensee did not comply with the section cited above in two (2) bathrooms had a reading of 127.4 and 128.1 which poses an immediate health, safety or personal rights risk to persons in care.

POC: Admiistrator lowered water at time of visit. Facility wil create a water log for one week and send to LPA.

On today’s visit, LPA received confirmation via email from S1 of the water temperature log dated 8/01/2026 to 8/10/2026. Deficiency cleared as of 8/10/2026.

(Continue to LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NEBULA HOME
FACILITY NUMBER: 197610514
VISIT DATE: 08/10/2026
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On 8/01/2026, citation Type A was issued: 80075(b)(5)(B) Health-Related Services: Based on record review, the licensee did not comply with the section cited above C2 was missing two (2) daily medications and seven (7) PRN medications which poses an immediate health, safety or personal rights risk to persons in care.

POC: Administrator will fill all missing medication or obtain a DC letter for medication in question.

Daily: Gabapentin 200 mg 3x a day and Wegovy 1.5 1 tab daily.

PRN:Benzonatate,albuterol,zofran,naproxen,tylenol with codeine,docusate, and anyi-diarrhe 2 mg.

On today’s visit, LPA received confirmation via email from S1 of the medication corrections pertaining to C2. Deficiency cleared as of 8/10/2026.

There were no immediate health and safety hazards observed during the day of inspection. Exit interview was conducted and a copy of this report was provided to designated care staff (S2).

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026
LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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