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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609728
Report Date: 05/19/2024
Date Signed: 05/19/2024 10:30:36 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2023 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 31-AS-20230919093151
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:
05/19/2024
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Alexandro Cuevas/DSPTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff inappropriately handled a resident while in care.
INVESTIGATION FINDINGS:
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On 5/19/2024 LPA Alfonso Iniguez conducted a subsequent unannounced complaint visit. LPA Iniguez met with Alexandro Cuevas/DSP. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#2), Client’s interviews (C#1-C#3) and Witnesses interviews(W#1-W#3). LPA obtained and reviewed the following documents: Client’s roster, Personnel roster, (C#1-C#3) Identification and Emergency Information, (C#1-C#3) Admissions agreements, (C#1-C#3) Physicians Report for Residential Care Facilities for the Elderly, (C#1-C#3) Needs and Services Plan, (C#1-C#3) Medication Administration Record (MAR) for the month of May 2024, (C#1-C#3) and copy of staff training regarding personal of residents.

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024
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 4
Control Number 31-AS-20230919093151
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: TERNUS ADULT 2
FACILITY NUMBER: 197609728
VISIT DATE: 05/19/2024
NARRATIVE
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Investigation Revealed the Following:

Allegation: Staff inappropriately handled a resident while in care.

The details of the complaint alleged that facility staff inappropriately handle a resident in care.



During the records review, LPA Iniguez reviewed (A#1)’s training records which consisted of: Certificate of Continuing Education- An Introduction to the NADSP Code of Ethics from Department of Developmental Services dated: 1/9/24, Certificate of Continuing Education-Informed Decision Making from Department of Developmental Services dated: 1/10/24, Certificate of Behavior Function- from Brandon Guin, PhD, MFT, BCBA dated 4/26/2023, Certificate of Escape Function & Replacement Behaviors from Brandon Guin, PhD, MFT, BCBA dated 1/19/2024, Certificate of Completion-Harassment Prevention for Supervisors CA (2022) from CalChamber dated 11,11,2022, Certificate of Completion-Obsessive Compulsive and Related Disorders from Community Training Connection dated 2/17/2024, Certificate of Completion- Autism Spectrum Disorder from Community Training Connection dated 1/23/2024, State of California Department of Social Services Community Care Licensing Division effective date: 3/4/2022 to 3/3/2024 and Certificate of Completion- Adult Residential Facility Initial Certification from Community Training Connection dated 10/12/2021. LPA Iniguez observed (A#1) has the necessary training on file.

In addition, LPA Iniguez reviewed all facility staff records. Each record contained the Personal Rights Adult Community Care Facilities sheet signed by the facility staff. Moreover, (A#1) provided a copy of an email from BCBA with a Zoom link regarding personal rights dated 3/15/2024. The training was for all facility staff.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20230919093151
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: TERNUS ADULT 2
FACILITY NUMBER: 197609728
VISIT DATE: 05/19/2024
NARRATIVE
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During the client's records review, LPA Iniguez checked the (C#1-C#3) 's Physician's Report for the Residential Care Facilities for the Elderly (RCFE) or LIC 602A. LPA Iniguez observed that (C#1-C#3) cannot communicate frequently.

During a physical tour of the facility, LPA Iniguez observed that the facility was clean, sanitary, and in good repair. In addition, LPA observed that knives and cleaning supplies were locked, secured, and inaccessible to clients in care. Also, LPA observed that the client’s medications were centrally stored and locked. Furthermore, LPA observed plenty of perishable and non-perishable food at the facility. Moreover, LPA inspected the client’s rooms, bed, and bedding, which were in good condition and appropriately furnished during the visit.

During an interview with the administrator (A#1), he stated that he is aware of the client’s rights, and he and the rest of the staff train every six months with the facility’s BCBA. In addition, (A#1) stated that he has never violated the personal rights of the clients in care and has never handled a client inappropriately.

During interviews with Clients (C#1-C#3) on 5/18/24, Licensing Program Analyst (LPA) Alfonso Iniguez conducted a subsequent complaint visit. Due to cognitive impermanence, the LPA could not interview all clients in care.

During interviews with staff (S#1-S#2), (2) out (2) stated that they are aware of the personal rights of the clients in care, and every six months, they take training regarding the personal rights of clients. In addition, (2) out of (2) facility staff stated that they have never violated the individual rights of the clients in care and have never handled a client inappropriately.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20230919093151
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: TERNUS ADULT 2
FACILITY NUMBER: 197609728
VISIT DATE: 05/19/2024
NARRATIVE
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During the Interviews with Witnesses (W#1-W#3), (3) out of (3) stated that they were knowledgeable about the client’s rights and that they had never observed a facility staff violating the client’s rights. In addition, (3) out of (3) witnesses stated that they have never observed a facility staff handling a client inappropriately in care, and they think the facility is safe for the clients to live in.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.


An exit interview was conducted, and a copy of the Complaint Report was given to Alexandro Cuevas/DSP.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4