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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610716
Report Date: 07/03/2025
Date Signed: 07/03/2025 03:26:24 PM

Document Has Been Signed on 07/03/2025 03:26 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:CASA ABELIAFACILITY NUMBER:
197610716
ADMINISTRATOR/
DIRECTOR:		SARABOSING, GWENFACILITY TYPE:
740
ADDRESS:29521 ABELIA RDTELEPHONE:
(917) 669-9284
CITY:CANYON COUNTRYSTATE: CAZIP CODE:
91387
CAPACITY: 6CENSUS: 0DATE:
07/03/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Gwen Sarabosing/LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Nadia Shahbazian conducted a pre-licensing visit and inspection of the facility. LPA met with Gwen Sarabosing-Licensee/Administrator at 9:30am. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on November 5, 2024. A fire clearance was granted for five (5) non-ambulatory and one (1) bedridden residents for a total capacity of six (6).

At approximately 10:30am, with the assistance of administrator, LPA took a tour of the physical plant and observed the following:

Required postings were observed in the receiving area and the kitchen. Facility has four new fire extinguishers that were purchased on November 05, 2024; fire extinguishers are located in receiving area, dining room, kitchen and office. Facility is equipped with four fire doors, in the hallway, in living room and bedrooms #3 and #4. The smoke alarms and carbon monoxide detectors are hard wired and inter-connected. At approximately 10:45am, smoke alarms/carbon monoxide detectors were tested and were observed to be functional. During the smoke/carbon monoxide test, LPA observed the fire doors properly closed automatically.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. All entry and exit doors have a functional auditory alert alarm when the doors open. The backyard of the facility has a covered patio large enough to hold outdoor activities. There was adequate backyard furniture. There is no swimming pool or body of water. There are two locked sheds, used to store supplies and furniture. The main entrance door and the dining room sliding door will be used for emergency exit use. There are two side gates leading to the front. There are exits in dining room, bedrooms #3, #4 and #5, all leading to the backyard. All exits were observed to be free of obstruction and were designated with exit signs atop each door.

(continued in 809-C)
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2025
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 3
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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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: CASA ABELIA
FACILITY NUMBER: 197610716
VISIT DATE: 07/03/2025
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Kitchen: The kitchen is equipped with a refrigerator, microwave, stove/oven and dishwasher. The appliances and fixtures were all functional. There is sufficient amount of dishes in kitchen cupboards. Even though facility does not have any residents, LPA observed enough perishable food supplies for 3 days and non-perishable food for 7 days. Knives and sharp objects were properly stored in a locked drawer in the kitchen and chemicals were locked underneath the kitchen sink cabinet. Medications will be locked in the kitchen cabinet; the first aid kit and the manual will also be kept in the kitchen.

COMMON AREAS: The entrance door opens to the receiving area, which has a covered fireplace; no fireplace tools are present. Resident files will be kept in the locked cabinet in the receiving area. The dining and living rooms are located next to the kitchen. The dining area has a large table to accommodate six (6) residents. The living room has a television set and ample sitting, which will be used for activities and game area. Facility is equipped with internet access and land line telephone. There are three storages, one near the entrance door and two in the hallway.
BEDROOMS: There are five (5) bedrooms designated for client use. Each bedroom is furnished with beds, night stands, chairs, closets, chest drawers, tight-fitting, lidded trash cans, bedding and linens. Bedroom #3 is a shared room and is designated as the bedridden resident room.

BATHROOMS: The facility has three (3) full bathrooms. There is a bathroom across bedroom #1. Bedroom #3 has a full bathroom; bedrooms #4 and #5 have a shared full bathroom. All bathrooms were observed to have the proper fixtures, grab bars and anti-slip flooring. Hot water delivered in the bathrooms measured between 118-118.4 degrees Fahrenheit.



OFFICE SPACE/CARE GIVER ROOM: Facility's garage is located at the front and was converted to a one bedroom unit for the staff use. The conversion was permitted as staff/care giver room; the unit has it's own bedroom, bathroom and kitchen. Office workstation consists of a desk and locked filing cabinets, in order to store confidential staff records. The office/care giver room may be used for living-in staff purposes but administrator will ensure to have an awake staff at all times, at the facility. Laundry machine and chemicals are locked in the staff room, inaccessible to residents.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Nadia Shahbazian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
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