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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850248
Report Date: 08/08/2022
Date Signed: 08/08/2022 12:45:42 PM

Document Has Been Signed on 08/08/2022 12:45 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:TERNER HOME 1FACILITY NUMBER:
195850248
ADMINISTRATOR:BAGDASARIAN, SIRANUSHFACILITY TYPE:
740
ADDRESS:13921 CANTLAY ST.TELEPHONE:
(818) 326-0336
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 4DATE:
08/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Siranush Bagdasarian, AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Salia Walker conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Siranush Bagdasarian. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been requested.

The facility is one story. At 10:10 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents; and, one (1) of bedridden residents. The facility has three (3) shared resident room(s). Resident room #3 has direct exit to the outside, and is cleared for one (1) bedridden resident. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are no staff rooms, ‘awake night staff only’ is required. All rooms were free of odors. All window screens were clean and maintained in good repair. There are two (2) common bathrooms in the hallway. Common bathroom #2 is designated as a staff bathroom. The resident bathroom(s) has a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 120*F. Resident and staff records are stored in a locked closet which is currently located in the hallway upon entry. Medications are centrally stored in a locked closet located in the hallway upon entry. The first aid supplies were complete, including a thermometer and a current version of a first aid manual was assessable in the same location as the central entry point for symptom screening, temperature checks, and sanitation station.

Continue on LIC809C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: TERNER HOME 1
FACILITY NUMBER: 195850248
VISIT DATE: 08/08/2022
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Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in the facility garage. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room. It is screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are two (2) fire extinguishers throughout the house. They are fully charged with an expiration date of 04/23/2022. The supply of extra bed and bath linens is adequate. Personal hygiene items were adequate and are stored in in each bathroom. Extra incontinence supplies are stored in the facility garage. The garage is accessible from the house; and the door was locked and secure. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in the living room. Other required postings are posted in the hallway. The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by gates at the north and south side passageways. There are two (2) side gates with a self-latching mechanism for persons to enter the front yard. There are no bodies of water on the premises at this present time.
Continue on LIC809C..
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: TERNER HOME 1
FACILITY NUMBER: 195850248
VISIT DATE: 08/08/2022
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Comp III conducted.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new facility license number, until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

The physical plant of this facility location is in compliance with Title 22 regulations at this time. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
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