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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609327
Report Date: 08/19/2024
Date Signed: 08/20/2024 08:09:57 AM

Document Has Been Signed on 08/20/2024 08:09 AM - 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/
DIRECTOR:		TERNUS, TYLERFACILITY TYPE:
735
ADDRESS:43513 62ND STREET WESTTELEPHONE:
(661) 802-4849
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Tyler TernusTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 08/19/2024 at 1:00 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced required annual inspection. LPA knocked on the door and nobody answered. LPA contacted the administrator Tyler Ternus and explained the reason for the visit. Administrator informed LPA clients were at their day program but that the house manager will be able to meet LPA. LPA met with the house manager, Cesar Solis who granted access. Administrator met LPA after.

The facility has a fire clearance for four (4) ambulatory clients with a total capacity of four (4).The facility is a two story home with (4) private bedrooms and three (3) bathrooms.

A tour of the physical plant was conducted with the house manager at approximately 2:50 p.m. and the following was observed:

Food Inspection: LPA conducted a tour of the kitchen 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 box 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 07/12/2024.
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. Activity area was clean and clear of clutter and stores bored games and crafts for clients in care.
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. (Continued on LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TERNUS ADULT
FACILITY NUMBER: 197609327
VISIT DATE: 08/19/2024
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(Continued from LIC809)
LPA observed the house manager test a smoke detector at 3:05 p.m. Detector are interconnected to other detectors located through out the facility. LPA observed smoke detectors functioning properly. LPA tested the carbon monoxide detector and it was observed to be functioning properly.

Bathrooms: The facility has three (3) bathrooms. One (1) is located in a client's private bedroom. LPA observed all 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. LPA observed a supply of PPE available for clients, staff and visitors through out the facility.

Laundry: Laundry room is located by the bedrooms and is accessible to clients and staff. Detergents and cleaning supplies 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. There are no bodies of water.

Garage: The garage is attached and maintained locked.

Client/Staff Records: LPA reviewed four (4) out four (4) client records and (7) out of seven (7) staff records 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 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. Facility keeps Medication Administration Records (MAR).

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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