197609029-8-17-2023-31-AS-JGTN-CUSUCZ-20230817152845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609029
Report Date: 08/17/2023
Date Signed: 08/17/2023 03:29:24 PM

Document Has Been Signed on 08/17/2023 03:29 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:	TERNER CARE		FACILITY NUMBER:	197609029
ADMINISTRATOR:	TER-NERSESIAN, ANDRANIK A		FACILITY TYPE:	740
ADDRESS:	13800 WHEELER AVENUE		TELEPHONE:	(818) 665-9631
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY:	6	CENSUS: 5	DATE:	08/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:28 AM
MET WITH:	Andranik Ter-Nersesian - Administrator		TIME COMPLETED:	03:30 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) Gary Tan, met administrator Andranik Ter-nersesian for a One (1) Year Required visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 11:44 AM and the following was noted: There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside and inside. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has four (4) bedrooms and two (2) bathrooms currently occupying five (5) residents. One (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, (6) one (1) of which may be bedridden. Hospice waiver for two (2). Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 76°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguisher is located in the dining area and observed to be full and last bought on 05/17/23. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The swimming pool is appropriately fenced and observed to be locked. (continued on LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

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

FACILITY NAME: TERNER CARE	FACILITY NUMBER: 197609029
	VISIT DATE: 08/17/2023

NARRATIVE

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(continued on LIC 809-C)

There is no garage at the facility, only car port located at the front. The garage was converted as an Additional Dwelling Unit (ADU), it has a separate ingress and egress and a different address. Laundry room is located adjacent to the kitchen. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the laundry area. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at 110.1°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed medication in the hallway cabinet to be locked and inaccessible to residents. There were two (2) complete first aid kits located in the kitchen.

Client records: Client records are reviewed. Client records appear to be complete and updated.
Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. Disaster drill was last conducted on 06/24/23. Required posting observed in facility (complaint hot line poster).

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023

LIC809 (FAS) - (06/04)

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