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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609327
Report Date: 12/20/2023
Date Signed: 12/20/2023 03:21:22 PM

Document Has Been Signed on 12/20/2023 03:21 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TERNUS ADULTFACILITY NUMBER:
197609327
ADMINISTRATOR:TERNUS, TYLERFACILITY TYPE:
735
ADDRESS:43513 62ND STREET WESTTELEPHONE:
(661) 802-4849
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Tyler TernusTIME COMPLETED:
03:45 PM
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On 12/20/2023 at 12:30 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced required annual inspection. LPA was greeted by administrator Tyler Ternus and granted access. LPA explained the reason for the visit. Entrance Interview conducted.

The facility has four (4) bedrooms and three (3) bathrooms. The facility is Fire Cleared for four (4) ambulatory clients.

A tour of the physical plant was conducted with administrator at approximately 12:35 p.m. and the following was observed:

Food Inspection: LPA conducted a tour of the kitchen at approximately 12:35 p.m. and observed there to be sufficient supply of two-day perishables and seven-day non-perishables foods, properly stored. Food storage and preparation areas are clean and clear of clutter. LPA observed all knives, sharp object, locked in a lock bock in a kitchen cabinet and inaccessible to clients in care. There are two (2) fire extinguishers one (1) located in the kitchen observed to be fully charged with last serviced date 06/19/2023.

Living and dining areas: LPA observed the living area and dining area to be clean and clear of clutter. The furniture was in good repair and sits the capacity of the facility. LPA observed a fireplace in the living area secured with a screen.

Bedrooms: LPA inspected four (4) out of four (4) client bedrooms. Bedrooms are for private use. LPA observed each client room to be properly furnished with one bed, appropriate night stand, chair, bedding and with sufficient lighting and storage.

LPA observed administrator test a smoke detector at 12:51 p.m. Detector is interconnected to other detectors located through out the facility. Carbon monoxide detector was observed to be functioning properly.
(Continued on LIC809-C)
Eva Miller
Evelin Rios
DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TERNUS ADULT
FACILITY NUMBER: 197609327
VISIT DATE: 12/20/2023
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(Continued from LIC809)

Bathrooms: The facility has 3 bathrooms. One (1) is located in the client's private bedroom. LPA took water temperature from one (1) out three (3) bathrooms and temperature was 110.9 degrees F. LPA observed the bathrooms to be clean and properly supplied with hand soap, toilet paper, paper towels and trash bins with lids.

LPA observed a closet with emergency food, water and supplies for a disaster. LPA observed the first aid kit with manual up to date.

Laundry: Laundry room is located by the bedroom and is accessible to clients and staff. Detergents are kept locked in a closest in the laundry room.

Surrounding Grounds: Entry and exits were free of obstructions. There is a covered patio with appropriate furniture for client use.

Garage: The garage is attached and maintained locked.

Client/Staff Records: At approximately 1:48 p.m. four (4) out four (4) client records and (2) staff records were reviewed to insure compliance with licensing forms. Records are kept locked in the facility office.

Medications: Centrally stored medications are maintained in locked boxes in the locked facility office. Medications were observed locked. One pharmacy is being utilized for resident use. Refills are either done automatically or ordered by the physician. Medication Records were reviewed for proper documentation. Medication records are maintained manually.


Pursuant to Title 22 Division of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A Copy of the Report Issued.
SUPERVISOR'S NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023
LIC809 (FAS) - (06/04)
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