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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609728
Report Date: 02/02/2023
Date Signed: 02/03/2023 11:00:30 AM

Unsubstantiated


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
09/06/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220906154645
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: DATE:
02/02/2023
UNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Tyler TernusTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff physically abused resident in care
Resident sustained unexplained injury while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA conducted an unannounced visit and was greeted by caregiver at the front door. LPA stated the purpose of the visit was to investigate the complaint which states staff physically abused resident in care and resident sustained unexplained injury while in care. The Administrator arrived at 8:10 am, LPA and the Administrator toured the facility at 8:20 am until 8;34 am. LPA did not observe any health or safety issues.

LPA interviewed the caregiver and one on one Brea Caregiver who both confirmed the resident (R1) incident occurred on September 5, 2022. Both stated R1 became upset and injured self the evening of September 5, 2022. Both confirmed that the Adminstrator was not at the facility. Based upon LPA's interview of the Administrator, the Administrator stated was not present at the facility on September 5, 2022. Also Complainant was unable to determine the specific date the event occurred and LPA interviewed the resident who was unable to provide information to LPA. Therefore the allegation is unsbustantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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