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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609029
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:02:05 PM

Document Has Been Signed on 08/26/2022 12:02 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TERNER CAREFACILITY NUMBER:
197609029
ADMINISTRATOR:TER-NERSESIAN, ANDRANIK AFACILITY TYPE:
740
ADDRESS:13800 WHEELER AVENUETELEPHONE:
(818) 665-9631
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 6CENSUS: 6DATE:
08/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Andy Ter-Nersesin & Eteri SimonyanTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced infection control inspection/visit. LPA was greeted by caregiver Eteri Simonyan who allowed LPA to enter the facility. Upon entering the facility, there was routine symptom screening, except for LPA to sign in the visitor book. Caregiver contacted Administrator Andy Ter-Nersesin, who was not able to attend the visit. LPA conducted mitigation review, via telephone and conducted a physical plant with caregiver Eteri. Administrator reported to LPA, that there have not been any active or past COVID cases at the facility. There current census is (6); there are (5) residents were vaccinated and (1) refused. All (4) staff are vaccinated. LPA observed hand sanitizing station, and PPE on the kitchen table. LPA observed Licensing and COVID-19 posting on the walls.

The infection control inspection was conducted throughout the facility. The facility has (4) bedrooms; with (2) shared room and (2) private. All common areas were observed to be clean, including bathrooms, that had soap and towels. Hand washing signs were visible. LPA conducted a mitigation plan review with the Administrator, to obtain information on how the facility has implemented the plan. Administrator reported they regularly conduct COVID-19 surveillance testing weekly. Visitation is conducted in resident’s rooms or outside on the back patio. Administrator reported that he only allows (2) visitors at a time. Residents eat together and practice social distancing at the dining room table.



There are designated rooms for potential positive COVID residents. PPE, chemicals, cleaning supplies, and paper products are stored in the garage area, which was locked and secured. LPA observed a (30) day supply of PPE, soap and paper products.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TERNER CARE
FACILITY NUMBER: 197609029
VISIT DATE: 08/26/2022
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LPA observed the facility has Licensing requirement for food supply. Currently, the facility has sufficient staff, and has back-up staff if needed. The facility has not had any positive COVID-19 reports for staff or residents. Administrator informed LPA that they continue to implement the best practices for their facility; which has kept them COVID-19 free. Staff have been trained and notified regarding sick and return to work policies. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview conducted and copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC809 (FAS) - (06/04)
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