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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850343
Report Date: 08/19/2024
Date Signed: 08/19/2024 06:14:16 PM

Document Has Been Signed on 08/19/2024 06:14 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 2FACILITY NUMBER:
195850343
ADMINISTRATOR/
DIRECTOR:		BAGDASARIAN, SIRANUSHFACILITY TYPE:
740
ADDRESS:7056 MATILIJA AVENUETELEPHONE:
(818) 326-0336
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 6CENSUS: 5DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:57 AM
MET WITH:Siranush Bagdasarian, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection using the complete CARE Inspection Tool and was let into the home by Eva Martirosian, Staff. Staff contacted Siranush Bagdasarian, Administrator via telephone and she arrived at 11:18am to conduct the visit. The reason for today's visit was provided.

The home is a single storey family home consisting of a living room, dining room, kitchen, four resident bedrooms, 2 full bathrooms, a staff lounge and a attached garage. The facility is fire cleared for 5 non-ambulatory residents and 1 bedridden resident. Bedroom #3 is approved for bedridden use.

On today's visit, all 12 domains of the CARE Inspection Tool was reviewed. Also reviewed on today's visit were 5 resident files and 5 staff files.

The following were observed on today's visit:
  • the living room, dining room and kitchen were equipped and furnished with the appropriate furnishings and equipment for its designated use. The fire place in the living room was covered with a fire screen.
  • Bedrooms #1 and Bedroom #3 are double occupancy rooms with 2 hospital bed, 2 night stand, 2 lamp, a built in dresser in Bedroom #1, a single dresser in bedroom #3, 2 chair and a closet.
  • Bedroom #2 and Bedroom #4 are single occupancy rooms with a hospital bed, a night stand, a chair, a lamp, a dresser and a built in closet in bedroom #2 and a portable closet in bedroom #4.
  • the common bathroom located by the front door has a toilet, 1 sink vanity, a shower stall equipped with grab bars and a non-skid mat. Water temperature was tested at 4:13pm tested and it read 116.8 degrees Fahrenheit
  • the common bathroom located by the resident bedrooms has a walk in shower, a single sink vanity, a
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 2
FACILITY NUMBER: 195850343
VISIT DATE: 08/19/2024
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  • toilet. Grab bars and a non-skid mat was observed. Water temperature was tested and read 117.6 degrees Fahrenheit. Located inside the bathroom is also the washing machine and dryer.j
  • fire extinguishers last inspected on 8/9/24 were observed in the living room and by Bedroom #2.
  • mattresses covers, fitted sheets and pillows were observed on all resident beds. Some residents were observed using a flat sheet or a blanket for covers. The beds were not fully made due to resident preference. Extra linens were observed in the linen closet located by the front door.
  • The auditory devices on the front door, back glass door and in bedroom #3 were all operational
  • the required posters were observed posted by the front door.
  • the hardwired smoke detectors were tested and were operational
  • the facility was missing a carbon monoxide detector.
  • the first aid kit was reviewed and met Title 22 requirements. Also observed was a first aid manual.
  • sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were maintained on the premises but could be supplemented with additional proteins and vegetables.
  • the facility has liability insurance for 1 million per occurrence and 3 million total aggregate and is currently being reviewed since the policy covers 3 separate locations under the same policy. Any deficiencies determined after review will be cited at a later date. Licensee submitted a copy of the Declaration page for Department review.
  • The backyard has a covered patio and is furnished with rattan patio chairs.
  • The outside areas, front and back were observed to be clean and well maintained.



Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8

Exit interview was conducted, APPEALS RIGHTS discussed and a copy was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
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Document Has Been Signed on 08/19/2024 06:14 PM - It Cannot Be Edited


Created By: Christine Yee On 08/19/2024 at 05:56 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 2
FACILITY NUMBER: 195850343

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above per tour of the facility, it was observed that the facility did not have a carbon monoxide detector in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2024
Plan of Correction
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Licensee will do monthly inspections to ensure that the carbon monoxide detector is present in the faciity and that it is operational.
**********a carbon monoxide detector was purchased and placed in the dining room during today's 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: 08/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2024


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