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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609327
Report Date: 07/18/2022
Date Signed: 07/18/2022 02:34:02 PM

Document Has Been Signed on 07/18/2022 02:34 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
CCLD Regional Office, 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:
07/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Tyler Ternus, AdministratorTIME COMPLETED:
02:45 PM
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On 7/18/22, Licensing Program Analyst (LPA) Shira Stamps arrived at the facility for an unannounced one (1) year Required visit. LPA arrived at 1:40 pm. LPA was greeted by the Administrator, and LPA informed him of the purpose of the visit.

A tour of the physical plant was conducted with the Administrator at 1:45 pm. The facility has five (5) bedrooms and two (2) and a half bathroom currently occupying four (4) clients. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for four (4) ambulatory.

Infection control: LPA reviewed the mitigation plan approved on 5/07/21. The facility is following current infection control recommendations. Upon arrival LPA was screened by the Administrator and asked all infection control questions. LPA was asked to sign-in and sanitizer was available.

Living and dining
At 1:55pm, LPA observed the living room and dining room to be neat and clean. The facility maintains a temperature of 78°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 2:08 pm.

Food Inspection
LPA conducted a tour of the kitchen around 1:47 pm and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed the knives and sharp objects in a locked box in the kitchen cabinet. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced 06/03/22.
CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TERNUS ADULT
FACILITY NUMBER: 197609327
VISIT DATE: 07/18/2022
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Bathrooms
LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested at 2:03 pm and measured within regulation at 105.1 degrees F.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client. LPA observed the Staff room to be locked, and contained client files, 1st aid kit, and medications.

Laundry
The Laundry room is located upstairs. LPA observed the locked closet to have chemicals/hazardous items. LPA observed the second (2) fire extinguisher to be full and last serviced 06/03/22.

Garage
At 1:50pm, LPA observed the locked garage to be attached to the facility and is currently being used for storage and an extra refrigerator.

Physical environment
LPA toured the outside area of the facility at 1:52pm. LPA observed a covered shaded area for clients. There are no bodies of water on the premises.

Administrative: LPA reminded the Administrator to submit the infection control plan to their LPA.

An exit interview was conducted, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2