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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850248
Report Date: 08/14/2024
Date Signed: 08/14/2024 04:58:25 PM

Document Has Been Signed on 08/14/2024 04:58 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:TERNER HOME 1FACILITY NUMBER:
195850248
ADMINISTRATOR/
DIRECTOR:		BAGDASARIAN, SIRANUSHFACILITY TYPE:
740
ADDRESS:13921 CANTLAY ST.TELEPHONE:
(818) 326-0336
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 6DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:56 AM
MET WITH:Siranush Bagdasrian, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool. LPA Yee was let into the home by Gohar Hovhannisyan, Staff. Siranush Bagdasarian, Administrator was contacted by staff and she arrived at 11:13am to conduct the visit.

The facility is a single storey family home consisting of a living room, a dining room, a kitchen, 3 resident bedrooms, 2 common bathrooms and a attached garage. The facility is fire cleared for 5 non-ambulatory and one bedridden resident. Bedroom #3 is the room designated for the one bedridden resident.

The following domains were reviewed on today's visit: Infection Control, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/Incident Reports and Disaster Preparedness. Due to time constraints, the following domains will be reviewed on a return visit: Physical Plant/Environmental Safety and Residents with Special Health Needs. Also reviewed on today's visit were 6 resident files and 5 staff files.

Deficiencies noted during the reviewed domains and file review are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8. Any deficiencies not addressed on today's visit will cited on a return visit. CIVIL PENALTIES WERE ASSESSED on today's visit.


Exit interview was conducted, APPEALS RIGHTS were discussed and a copy was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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Document Has Been Signed on 08/14/2024 04:58 PM - It Cannot Be Edited


Created By: Christine Yee On 08/14/2024 at 04:13 PM
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TERNER HOME 1
FACILITY NUMBER: 195850248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above per review and verfiication of Departments records, Gohar Arami Khotsanyan, Staff obtained a criminal record clearance but was not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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Licensee will ensure that all staff and volunteers have obtained a criminal record clearance and are associated to the faciity prior to working, residing or volunteering in a licensed facility. Licensee will associate Gohar Arami Khotsanyan to the facility. *******Gohar Arami Khotsanyan was associated to the facility via Guardian during the visit*******
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2024 04:58 PM - It Cannot Be Edited


Created By: Christine Yee On 08/14/2024 at 04:30 PM
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TERNER HOME 1
FACILITY NUMBER: 195850248

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
87458 Medical Assessment
(b) The medical assessment shall include, but not be limited to:
(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above per review of Resident #3 and Resident #6 facility files, neither residents' files were observed with a Physician's Report with evidence that a TB test was completed and the results of the test noted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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The Licensee will contact the residents' physician to either obtain the results of the TB test that may have been conduct or schedule a doctor appointment for each resident to be tested to ensure that the residents do not have TB or any other communicable/infectious disease or other medical condition that would preclude care of the person by the facility by 8/21/24. If additional time is needed, please request an extension prior to the due date of the plan of correction.
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:Kristin Heffernan
LICENSING EVALUATOR NAME:Christine Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
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