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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609728
Report Date: 11/14/2024
Date Signed: 11/14/2024 01:23:40 PM

Document Has Been Signed on 11/14/2024 01:23 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
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:
11/14/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Tyler TernusTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit on 11/14/2024. LPA was greeted by the caregiver. LPA stated the purpose of the visit was to complete an annual inspection. The Licensee, Tyler Ternus arrived at 8:45 am. The facility is licensed for four ambulatory residents and there are four residents living in the facility.

LPA Spaeth viewed the residents' records at 8:20 am until 8:44 am. LPA reviewed staff files at 8:45 am until 9:10 am. LPA Spaeth and the Licensee reviewed the P&I funds at 9:15 am until 9:26 am; however the records were not accurate. LPA Spaeth reviewed resident's medication at 9:30 am.

LPA Spaeth and the Licensee began the tour at 9:30 am until 9:55 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. The kitchen contained a kitchen table and chairs. The family room contains 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.



Continued on 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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: 11/14/2024
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Laundry Room - The washer and dryer were located in the room.

Garage – The garage was locked. Laundry detergent, cleaning supplies, 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 9:20 am and was 111 degrees F.

Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 9:50 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.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).


Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2024 01:23 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 11/14/2024 at 10:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TERNUS ADULT 2
FACILITY NUMBER: 197609728

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)(1)
80026 Safeguards for Cash Resources…(h) Each licensee shall maintain accurate records of accounts of cash resources…(1) Records of clients’ cash resources maintained as a drawing account, which shall include a current ledger accounting…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above. The clients' cash resources (P&I) were not accurate which poses a personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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The Licensee will correct the errors and forward copies of the documentation to LPA via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


LIC809 (FAS) - (06/04)
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