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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609728
Report Date: 02/15/2022
Date Signed: 02/15/2022 03:59:18 PM

Document Has Been Signed on 02/15/2022 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ryan GannTIME COMPLETED:
04:05 PM
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At approximately 2:00 PM on 02/15/22, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection using the Infection Control Domain of the Compliance and Regulatory Enforcement (CARE) Tools. LPA met with staff and disclosed the reason for the visit.

Census: 4

Entry: At the main entrance, LPA observed emergency water supply and a sign on the front indicating the facility’s visitation policy. Once inside, LPA observed a confidential complaint posting and personal rights posting.

Screening: Upon entry, LPA was screened by staff. LPA recorded temperature, symptoms, and contact tracing information in a visitor log. LPA observed a screening station which contained a wall-mounted digital thermometer, a handheld digital thermometer, surgical masks, N95 masks, and sanitizer. LPA also observed a daily client temperature log.

At approximately 2:10 PM, LPA conducted a physical plant tour.

Safety: LPA observed Emergency Evacuation Plans with routes clearly labeled at the front entrance. Smoke detectors were functioning. Water temperature tested in Bathroom #1 was 118.2 degrees Fahrenheit and 115.5. degrees Fahrenheit in the kitchen. The emergency exits path was clear and unlocked with an inward latch.

Bedrooms: The facility had 4 private bedrooms. All bedrooms contained adequate storage space, clean linens, televisions, nightstands, and lights. In the event of a COVID positive client, the facility will designate Bedroom #4 as an isolation room.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TERNUS ADULT 2
FACILITY NUMBER: 197609728
VISIT DATE: 02/15/2022
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Bathrooms: The facility had 3 bathrooms. Bathroom #1 is near Bedroom #1. Bathroom #2 was near Bedroom #2 and Bedroom #3. Bathroom #3 is adjacent to Bedroom #4. All bathrooms contained fully stocked liquid soap, paper towels, handwashing instruction signs, trash cans with tight-fitting lids, and non-skid mats.

Common Area: All common areas were clean. All furniture was in good repair. Seating at the dining table and television area were arranged to accommodate social distancing. All floors and ceilings were clean as well. The facility maintains a schedule for living room use to accommodate social distancing. LPA observed signs throughout the facility pertaining to coughing etiquette, social distancing, cleaning procedures, PPE donning and doffing, and signs and symptoms of COVID-19. LPA also observed the facility’s cleaning log, activity schedule, and weekly menu.

Kitchen: LPA observed adequate supplies of perishable food in the fridge and non-perishable food.

Storage: Near the kitchen, LPA observed a locked closet with resident medications, files, and sharp objects.

Outside space: LPA observed a covered patio area for visitation, a gas grill, and a well-maintained yard.

Garage: LPA observed a locked garage with cleaning supplies, detergents, extra PPE, and extra perishable food in a refrigerator. In a locked laundry room, LPA observed operating laundry machines and additional PPE.

LPA conducted exit interview and issued report.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
LIC809 (FAS) - (06/04)
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