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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609728
Report Date: 10/12/2023
Date Signed: 10/13/2023 07:41:20 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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: 3DATE:
10/12/2023
UNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Tyler TernusTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff physically abused resident in care
Resident sustained unexplained injury while in care.
INVESTIGATION FINDINGS:
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This is an amended copy of the report previously issued on 02/20/2023. This report supersedes the report previously issued. The findings for this complaint remain the same.

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced subsequent complaint investigation for the allegation(s) listed above. LPA met with Administrator Tyler Ternus and explained the purpose of the visit.

The investigation consisted of the following: On 09/07/2022, LPA Spaeth conducted a 24-hour visit, requested documents, interviewed C1 and interviewed the Administrator. On 02/02/23, LPA interviewed two out of five staff who were present during the alleged incident.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
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 2
Control Number 31-AS-20220906154645
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/12/2023
NARRATIVE
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Regarding the allegation: Staff physically abused resident in care. It’s being alleged that a resident is being hit while in care. LPA Spaeth interviewed W1 and S1 who both stated on 9/06/2022 they took C1 and C2 to dinner When they returned to the facility, S1 stated C1 became upset, ran to their room, went into their closet, fell down on a small scooter and injured themself. W1 observed C1 running to their room, was upset, and laying in the closet. W1 and S1 both stated the Administrator was not present at the facility.

Regarding the allegation: resident sustained unexplained injury while in care. It is being alleged that bruising was visible on C1s neck and back. LPA interviewed C1 and C1 was not able to confirm the allegation. W1 and S1 both stated C1 exhibits self-injurious behavior and confirms the Administrator was not present at the facility on the alleged incident. During an interview with the Administrator, they confirmed being out of town on 9/6/2022. During a record review, LPA reviewed C1’s Individual Program Plan (IPP) which cites that C1 has a history of self-injurious behavior and will bite, hit or scratch self.

Based on interviews conducted, and records reviewed, the allegations are unsubstantiated.

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

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2