197610212-10-24-2024-31-AS-JGTN-DACUMP-20241024154241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610212
Report Date: 10/24/2024
Date Signed: 10/24/2024 03:43:08 PM

Document Has Been Signed on 10/24/2024 03:43 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:	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: 6	DATE:	10/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:11 PM
MET WITH:	Siranush Bagdasarian - Administrator		TIME COMPLETED:	03:45 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) Gary Tan conducted an Annual Required inspection of this facility today. LPA met with the administrator, Siranush Bagdasrian and explained the reason for the visit. A tour of the physical plant was conducted at 12:39 PM and the following was noted: There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted inside. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has four (4) bedrooms and three (3) bathrooms currently occupying six (6) residents. One (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents. Hospice waiver for six (6) residents. 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: All four resident rooms were properly furnished with appropriate beddings and linens with sufficient lighting. (continued on LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

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: TERNER HOME	FACILITY NUMBER: 197610212
	VISIT DATE: 10/24/2024

NARRATIVE

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(continued from LIC 809)

Bathrooms: The bathrooms in use for residents were observed to have grab bars, non-skid mats and properly supplied with hygiene products. Hot water temperature was measured at a range of 116.8°F 117.4°F. 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 fireplace is non-operational and there was a glass and screen door in place. There are two (2) fire extinguishers, one (1) is located in the dining area and one (1) is near the main entrance. Fire extinguishers were last bought on 10/24/24.

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 bedroom hallway and 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. There are two (2) complete first aid kits located in the medication closet.

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: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

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