195850248-8-22-2025-29-AS-CYEE-DKT244-20250822170318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850248
Report Date: 08/22/2025
Date Signed: 08/22/2025 05:03:41 PM

Document Has Been Signed on 08/22/2025 05:03 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 1		FACILITY NUMBER:	195850248
ADMINISTRATOR/ DIRECTOR:	BAGDASARIAN, SIRANUSH		FACILITY TYPE:	740
ADDRESS:	13921 CANTLAY ST.		TELEPHONE:	(818) 326-0336
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 6		CENSUS: 6	DATE:	08/22/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:10 AM
MET WITH:	Siranush Bagdasarian, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:10 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) 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 10:29am 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. No bodies of water were observed on the property. On today's visit all 12 domains of the CARE Inspection Tool was reviewed, 6 resident files and 5 staff files were also reviewed. A tour of the physical plant, inside and outside, was conducted. The following was observed on today's visit: the living room, dining room and kitchen were all appropriately furnished and equipped for it's designated use. The fire place had the required fire screen. all three bedrooms were all equipped with 2 each of the following: hospital beds, night stands, dressers, lamps, chairs and a built in closet. All the windows had blinds for privacy. The common bathroom by the resident rooms is equipped with a tub/shower, grab bars, shower chair, slip resistant mat, a toilet, another grab bar and a single sink vanity. Water temperature was tested and read 111.4 degrees Fahrenheit. continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TERNER HOME 1	FACILITY NUMBER: 195850248
	VISIT DATE: 08/22/2025

NARRATIVE

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the second bathroom, located by the kitchen, is equipped with a shower stall, a toilet and single sink vanity and is designated for staff use. Water temperature was tested and read 115 degrees Fahrenheit.
the attached garage is used primarily for storage and also houses the washer and dryer. Detergents, disinfectants , hygiene products and cleaning solutions are stored in a locked cabinet.
the perishable and non-perishable food supply stored in the garage and in the kitchen refrigerator were reviewed and met Title 22 requirements. The facility also has a single bucket containing emergency food supply. Per information provided, it contains 120 servings.
the facility has 2 fire extinguishers purchased on 8/17/25 and they are located in the the dining room and in the resident hallway.
the only carbon monoxide detector is located in the dining room. It was tested and was operational
the first aid kit was reviewed and met Title 22 requirements. First aid manual was observed.
the smoke detectors located in the 3 resident bedrooms, hallway and living room were tested and were operational.
the auditory devices on the four outside exiting doors - Bedroom #3, front door, kitchen door and the sliding glass door in the living room were operational.
All residents in the home were visually observed to be doing well.
The backyard has a covered patio with wicker chairs and a coffee table. The backyard was observed to be well maintained.
the trash cans stored in the front yard were observed to be tightly sealed. The front yard was also observed to be clean and well maintained.

Exit interview was conducted and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

LIC809 (FAS) - (06/04)

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