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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609728
Report Date: 12/18/2024
Date Signed: 12/18/2024 11:10:08 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
09/22/2023 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20230922084348
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: 4DATE:
12/18/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Anthony ContrerasTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff caused an injury to resident which resulted in hip surgery
Staff inappropriately restrained resident
INVESTIGATION FINDINGS:
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On 12/18/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth met with the house manager. LPA explained the purpose of this visit was to deliver the findings.

The investigation consisted of the following: On 9/26/2023, LPA conducted an initial visit and reviewed the residents' files and interviewed three out of the four clients. LPA received the staff phone numbers, incident reports, and client documents.

Regarding the allegation: Staff caused an injury to resident which resulted in hip surgery. It’s alleged a client recently had hip surgery due to an injury caused by staff members. LPA interviewed four out of the ten staff members (S1-S4) on 10/28/2024

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
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 2
Control Number 31-AS-20230922084348
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: 12/18/2024
NARRATIVE
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via phone call at 2:00 pm until 3:30 pm. S3– S4 confirmed a client was upset on 8/04/2023, threw themselves on the floor and landed on their hip.

S3-S4 both confirmed they did not touch the client during the incident. S3-S4 confirmed the client was holding their hip in pain. S3 immediately took C1 to the hospital. S1-S2 confirmed they did not witness the incident. LPA attempted to interview three out of the four clients (C1-C3) but was unable due to communication barriers. C4 was not available for an interview. The Administrator denied this occurred.

Regarding the allegation: Staff inappropriately restrained resident. It’s alleged that a client’s behavior escalated due to staff restraining the client. LPA interviewed four out of the ten staff members (S1–S4). S1-S2 confirmed on 9/15/2024 a client was upset, tried to harm themselves, and tried to harm S1-S2. S1–S2 both stated they did not restrain the client. S1-S2 stated they verbally redirected the client until the client calmed down. S3–S4 did not witness the incident. LPA attempted to interview C1-C3 but was unable due to communication barriers. C4 was not available for an interview. The Administrator denied this occurred.

Based on interviews and record review, the allegations are unsubstantiated.

Exit interview conducted and a copy of the report was given.

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

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC9099 (FAS) - (06/04)
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