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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609728
Report Date: 02/20/2025
Date Signed: 02/20/2025 10:44:51 AM

Document Has Been Signed on 02/20/2025 10:44 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TERNUS ADULT 2FACILITY NUMBER:
197609728
ADMINISTRATOR/
DIRECTOR:		TERNUS, TYLERFACILITY TYPE:
735
ADDRESS:39207 COCKNEY STTELEPHONE:
(661) 878-8433
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:30 AM
MET WITH:Anthony ContrerasTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit on 02/20/2025. LPA was greeted by the Back-Up Administrator, Anthony Contreras. LPA stated the purpose of the visit was to complete an annual inspection. The facility is licensed for four ambulatory residents and there are four residents living in the facility.

LPA Spaeth and the Administrator began the tour at 8:00 am until 8:30 am. LPA observed the following:

Office - LPA observed the office area contained locked cabinets and office equipment. LPA did not observe any safety issues within the room.

Common areas – The kitchen and family room are combined. A kitchen table and chairs are located in the kitchen. The family room is furnished with comfortable seating.

Kitchen – LPA observed a two-day supply of perishable food and a seven-day supply of non-perishable food. There were no cleaning solutions stored underneath the kitchen sink. The knives were safely locked in a cabinet. A fire extinguisher was located in the kitchen area.



Laundry Room - The washer and dryer were located in the room.


Continued on 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TERNUS ADULT 2
FACILITY NUMBER: 197609728
VISIT DATE: 02/20/2025
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Garage – The garage was locked. Laundry detergent, cleaning solutions, PPE, and hygiene items were stored in the garage.

Resident Rooms - The resident rooms contained bed, linens, night stand, lamp, closet and chest of drawers. The rooms were neat and clean.

Medications - The medications were locked in facility office area.

Resident files - The residents' files were locked in the facility office area.

Bathrooms – The bathrooms contained hand soap, paper towels, and covered trash cans.



Water Temperature – LPA tested the water at 8:05 am and was 119 degrees F.

Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 8:30 am and were operable.



Backyard - LPA observed the backyard which has a shaded area. The gate leading from the backyard to the front yard was not locked.

There are no deficiencies to report at this time. Exit interview conducted and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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