197610212-12-22-2023-31-AS-MCAA-CYRRHT-20231222120252

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610212
Report Date: 12/22/2023
Date Signed: 12/22/2023 12:02:58 PM

Document Has Been Signed on 12/22/2023 12:02 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:	TERNER HOME		FACILITY NUMBER:	197610212
ADMINISTRATOR:	BAGDASARIAN, SIRANUSH		FACILITY TYPE:	740
ADDRESS:	9946 COLUMBUS AVENUE		TELEPHONE:	(818) 326-0336
CITY:	MISSION HILLS	STATE: CA	ZIP CODE:	91345
CAPACITY:	6	CENSUS:	DATE:	12/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Siranush Bagdasrian		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Siranush Bagdasrian and explained the reason for the visit. At approximately 9:00am, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The facility has two fire extinguishers. One is located in the dining room, and the other by the front entrance. Fire extinguishers were purchased on 08/15/23. Smoke detectors and Carbon Monoxide detector were tested and function properly. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Bedrooms: There were four (4) bedrooms designated for residents' use. Bedrooms #1 and #3 are shared. Bedrooms #2 and #4 are private. All four resident rooms were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are three (3) bathrooms. Two are designated for residents' use, and one is for staff. The bathrooms in use for residents were observed to be properly supplied and had functional fixtures. Hot water temperature was measured at 107 degrees Fahrenheit. LPA did not observe any toxins or cleaning supplies in any of the bathrooms during the day's visit. Common Areas: These included the living room and dining area. The common areas were properly furnished. The dining room area and table is large enough to accommodate up to six (6) residents. The auditory alarms on all exit doors were on and functional at the time of the visit. The floors were clean and in good repair. The fireplace is non-operational, but there was a glass and screen door in place. Tools for fireplace were not present.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

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: TERNER HOME	FACILITY NUMBER: 197610212
	VISIT DATE: 12/22/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. The laundry area is located in the hallway near the resident rooms. It was locked at the time of the visit. Detergents and cleaning supplies are kept in a cabinet, locked
and inaccessible.

Garage: The garage was converted to and additional dwelling unit (ADU) with an approved certificate of occupancy dated 02/25/2020 and has a separate address.

Resident Files: Resident files are kept in a locked closet by the dining room. LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Staff files are kept in a locked closet, also by the dining room. LPA conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medications are kept in a locked closet in the dining room. Medications and Medication Records were reviewed for proper storage and documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2023

LIC809 (FAS) - (06/04)

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