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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609728
Report Date: 08/10/2022
Date Signed: 08/10/2022 12:17:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220502140529
FACILITY NAME:TERNUS ADULT 2FACILITY NUMBER:
197609728
ADMINISTRATOR:TERNUS, TYLERFACILITY TYPE:
735
ADDRESS:39207 COCKNEY STTELEPHONE:
(661) 878-8433
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:4CENSUS: 3DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Ryan GannTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Lack of supervision resulting in resident sustaining injuries.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent complaint visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit.

It is alleged that there was a lack of supervision from staff resulting in client #1 (C1) scrapping their knee and hitting their mouth on a coffee table. Initial visit was conducted by LPA Spaeth on 5/4/22 where interviews were conducted with facility staff and a service coordinator from an agency called BREA that provides one on one services to C1. Information from those interviews reveal that BREA staff provide one on one service to C1 from 6am-9am and then facility staff take over supervision for C1 Monday through Friday. On 3/25/22 at approximately 9am according to BREA staff they clocked out of their shift and let staff # 1 (S1) know. At the time S1 was seeing another client off to day program and C1 was left in the living room area unsupervised when they attempted to rip an air vent out of the wall and fell. Interviews also revealed that another staff (S2) who works for the day program C1 attends and also the facility was five minutes late picking up C1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20220502140529
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2
FACILITY NUMBER: 197609728
VISIT DATE: 08/10/2022
NARRATIVE
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S2 was interviewed and admitted to being late picking up C1 for day program. S2 is supposed to pick up C1 by 9am when BREA staff is leaving so their is no coverage lapse but on 3/25/22 arrived at approximately 9:05 am. Based on the information obtained during interviews it appears that C1 was unsupervised for a period of time which contributed to C1 scraping their knee and cutting their lip. Based on the information obtained through interviews this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220502140529
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2
FACILITY NUMBER: 197609728
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/10/2022
Section Cited
CCR
80078(a)
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Responsiblity for Providing Care and Supervision; The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement was not met as evidenced by:
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Corrected before visit. Facility met with Agency providing one on one services and extended the time where one on services is provided until C1 is picked up for Day Program so there will be no lapse in coverage.
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Based on interviews conducted C1 was not properly supervised on a ratio of 1:1 for an unspecified amount of time which led to C1 being injured. This posed an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3