195850248-8-16-2023-29-AS-CYEE-CURTN6-20230816145213

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850248
Report Date: 08/16/2023
Date Signed: 08/16/2023 02:52:41 PM

Document Has Been Signed on 08/16/2023 02:52 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TERNER HOME 1		FACILITY NUMBER:	195850248
ADMINISTRATOR:	BAGDASARIAN, SIRANUSH		FACILITY TYPE:	740
ADDRESS:	13921 CANTLAY ST.		TELEPHONE:	(818) 326-0336
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 6	DATE:	08/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Siranush Bagdasarian, Administrator		TIME COMPLETED:	03:00 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) Christine Yee conducted an unannounced required Annual Inspection visit using the complete CARE Inspection Tool. Gohar Hovhannisyan, Staff allowed LPA Yee entry into the facility. The Administrator was contacted by staff and she arrived at 9:56am to conduct the visit. The facility is a single storey family home consisting of a living room, a dining room, a kitchen, 3 resident bedrooms, 2 common bathrooms and a attached garage. The facility is fire cleared for 5 non-ambulatory and one bedridden resident. Bedroom #3 is the room designated for the one bedridden resident. The following was observed on today's visit: The dining room and living room have the appropriate furniture for 6 residents and was clean The fire place was observed with a metal fire screen A carbon monoxide detector was observed in the dining room The kitchen has the standard equipment - stove, refrigerator, toaster oven, coffee maker and dishwasher was observed to be operational and clean. Knives are stored in a locked drawer. sufficient perishable and non-perishable foods were observed in the kitchen and in the garage The three resident bedrooms all contained 2 hospital beds, 2 chairs, 2 lamps, 2 dressers, a shared closet and blinds for privacy. No window bars were observed. Appropriate bed linens were observed on residents' beds minus the comforter due to the heat. Comforter kept in the linen closet with extra bed linens The two common bathrooms were toured. The common bathroom located by the garage is designated for staff use and does not have grab bars. The common bathroom located by resident rooms has a bath tub with a shower. A shower chair, grab bars and non-skid mat were observed. Water temperature tested in the sink read 106.5 degrees Fahrenheit. Per Administrator, the thermostat will be adjusted to a

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TERNER HOME 1	FACILITY NUMBER: 195850248
	VISIT DATE: 08/16/2023

NARRATIVE

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mid-range setting.
The facility has 2 fire extinguishers purchased on 8/15/23. One is located in the dining room and one in the hallway by bedroom #3.
A first aid kit and first aid manual was observed.
Staff have current first aid training.
Administrator has a current certificate - expires 12/28/24
The hardwired smoke detectors were tested and were operational
Disinfectants, cleaning solutions and laundry detergents are stored in a locked cabinet in the garage. Also located in the garage are the washer and dryer and a second refrigerator for additional food
A tour of the outside was conducted at 12:54pm. A covered patio with chairs and coffee table was observed in the backyard. The front yard and back yard were observed to be clean and well maintained. There were no bodies of water observed. There are ramps installed from the living room exit and bedroom #3.
Trash cans stored in the front yard were observed opened and overfilled. One container had a discarded garden hose. Lids on the blue and green trash can were also cracked and need to be replaced.
The facility has a Infection Control Plan, Plan of Operation and an Emergency Disaster Plan on the premises

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/16/2023 02:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TERNER HOME 1	FACILITY NUMBER: 195850248
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(f)(3)

87303 Maintenance and Operation: (f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Licensee did not comply with the section cited above in 3 out of 3 trash cans observed. The trash cans were overfilled with trash and the lids could not be closed tightly. In addition to the lids being opened, the lids of the blue and green trash can were cracked and had holes which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	The Licensee will contact Los Angeles Sanitation and obtain new trash cans that are in good repair and can be closed tightly and are leakproof and rodent proof by 8/25/23. Provide photographs(pdf.file) of the replaced trash cans.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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