195850343-8-12-2026-29-AS-CYEE-DWW33D-20260812175321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850343
Report Date: 08/12/2026
Date Signed: 08/12/2026 05:53:35 PM

Document Has Been Signed on 08/12/2026 05:53 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TERNER HOME 2		FACILITY NUMBER:	195850343
ADMINISTRATOR/ DIRECTOR:	BAGDASARIAN, SIRANUSH		FACILITY TYPE:	740
ADDRESS:	7056 MATILIJA AVENUE		TELEPHONE:	(818) 326-0336
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 5	DATE:	08/12/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:36 AM
MET WITH:	Siranush Bagdasarian, Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:00 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 using the complete CARE Inspection Tool and was let into the home by Anush Nersesyan Staff. Staff contacted Siranush Bagdasarian, Administrator via telephone and she arrived at 11:02am to conduct the visit. Also present at the facility on today's visit was Kevin Poghosyan. The reason for today's visit was provided. The home is a single storey family home consisting of a living room, dining room, kitchen, four resident bedrooms, 2 full bathrooms, a staff lounge and a attached garage that was converted to an ADU with as separate address of 7058 Matilija Avenue and is not part of the facility operations. The facility is fire cleared for 5 non-ambulatory residents and 1 bedridden resident. Bedroom #3 is approved for bedridden use. On today's visit all 12 domains of the CARE Inspection Tool was reviewed. 5 Resident files and 6 Staff files were reviewed. A tour of the facility, inside and outside, was conducted. The following was observed on today's visit: The living room, dining room and kitchen are furnished and equipped with the appropriate furniture and equipment for its designated use. The fire place was observed with a fire screen to make it inaccessible to the residents in care. The four resident bedrooms, 2 are shared and 2 are private, are furnished with the required Title 22 furniture. Windows have the appropriate window dressings for privacy. The window screens were observed to be in good condition. continued on LIC809-C

Kristin Heffernan
Christine Yee
	DATE: 08/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

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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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TERNER HOME 2	FACILITY NUMBER: 195850343
	VISIT DATE: 08/12/2026

NARRATIVE

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The 2 common bathrooms are equipped with walk in showers, a toilet and a single sink vanity. Grab bars and slip resistant mats were observed in the shower and toilet. Also observed in the bathroom located in the resident hallway was a shower chair, a washer and a dryer. The water temperature tested in the resident bathroom read 112.2 degrees and the front bathroom read 109.9 degrees Fahrenheit.
The required postings were observed by the front door
The hardwired smoke detectors located in the resident bedrooms, resident hallway, by the front door and the single carbon monoxide detector located in the living room were tested and were operational.
The first aid kit was reviewed and met Title 22 requirements. A first aid manual was observed.
The facility has current general liability insurance that meets Title 22 requirements.
The facility is in the process of being the payee for Resident #4 and will provide evidence of a surety bond when the process has been completed.
The Administrator certificate is current.
All first aid training is current
The facility has 2 fire extinguishers, one located in the resident hallway by bedroom #2 and one in the living room, were serviced on 7/14/26.
The auditory devices located on the four outside exiting doors - back door, front door, bedroom #3 and kitchen were tested and were operational.
The backyard has a gazebo furnished with chairs and a coffee table for outside activity. Also located in the backyard is a large storage shed.
The trash cans stored in the front were observed to be tightly sealed.
Overall, the inside and outside areas were observed to be clean and well maintained.

Deficiency cited under California Code of Regulation, Title 22, Division 6, Chapter 8.

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

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/12/2026 05:53 PM - It Cannot Be Edited

Created By: Christine Yee On 08/12/2026 at 05:24 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: TERNER HOME 2	FACILITY NUMBER: 195850343
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as it was observed that Resident #2, Resident #3 and Resident #5 do not have current annual reappraisals on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/19/2026
	Plan of Correction
1 2 3 4	The Licensee will schedule a time and a date with the residents and their responsible party to discuss and update the residents care plan and maintain in the residents' files. Licensee will provide evidence that the reappraisal was completed by 8/19/26.

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.

	Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:

	Christine Yee
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2026

LIC809 (FAS) - (06/04)

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