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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610212
Report Date: 11/28/2022
Date Signed: 11/28/2022 02:52:03 PM

Document Has Been Signed on 11/28/2022 02:52 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 HOMEFACILITY NUMBER:
197610212
ADMINISTRATOR:BAGDASARIAN, SIRANUSHFACILITY TYPE:
740
ADDRESS:9946 COLUMBUS AVENUETELEPHONE:
(818) 326-0336
CITY:MISSION HILLSSTATE: CAZIP CODE:
91345
CAPACITY: 6CENSUS: 6DATE:
11/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Siranush BaghdasarianTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced One (1) Year Required Infection Control visit for this facility at 12:50 pm. LPA temperature checked upon entry and care staff contacted administrator. LPA spoke with administrator who revealed will arrive in approximately 15 minutes. Administrator arrived at the facility at approximately 1:30 pm and LPA disclosed the purpose of the visit.

LPA conducted a tour of the physical plant at 1:45 pm to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The facility has a total of four (4) bedrooms and three (3) bathrooms with two (2) bathrooms designated for clients’ and one (1) bathroom for staff or visitors use. Smoke detectors and Carbon Monoxide detector were tested and function properly.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the six (6) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk, and eggs observed. The freezer is stocked with meats and frozen vegetables. Sharps are stored in a locked drawer in kitchen. The clients’ medications are stored in locked closet in dining room observed to be inaccessible to clients. The first aid kits are readily available and stored on top of refrigerator in kitchen.

The fire extinguishers are attached to the walls in living room near pantry door and in dining room near dining room window. Fire extinguishers observed to be charged.

The client bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a sufficient supply of linens in hallway closet and backstock in pantry closet near front door. (Cont to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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 HOME
FACILITY NUMBER: 197610212
VISIT DATE: 11/28/2022
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(Cont fron 809)

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is within the required range for clients’ comfort and safety. The water temperature range was between 107.2- and 113.4-degrees Fahrenheit.

Common areas were observed for the ability to safely serve the needs of clients. These included the living room and dining room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed furnished appropriately.

Laundry area located in hallway behind locked doors and appliances observed to be functional. Toxins stored and locked under kitchen sink cabinet observed to be inaccessible to clients. An adequate supply of PPE’s, emergency food and supplies stored in shed in backyard observed to be locked and inaccessible to clients.

There are two (2) covered patio areas. First covered patio area has sofas and second patio area has patio table and chairs shaded by a large umbrella for clients use in the backyard. Patio furniture observed to be in good repair with adequate seating for the clients.

Facility grounds were free of hazards. There is no body of water in the facility. There were no immediate health and safety hazard observed during the day of inspection.

Exit interview conducted and copy of report given.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022
LIC809 (FAS) - (06/04)
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