197610422-7-11-2023-31-AS-ERIS-CTMR5S-20230711124336

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610422
Report Date: 07/11/2023
Date Signed: 07/11/2023 12:43:44 PM

Document Has Been Signed on 07/11/2023 12:43 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TERNER HEALTH		FACILITY NUMBER:	197610422
ADMINISTRATOR:	YAZICHYAN, EMANUEL		FACILITY TYPE:	740
ADDRESS:	4717 WEST AVENUE M4		TELEPHONE:	(661) 802-7960
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 6	DATE:	07/11/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Boris Adjamian / Owner		TIME COMPLETED:	01:00 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) Evelin Rios conducted a Pre-Licensing Inspection with the facility applicant, Boris Adjamian. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received 03/24/2023 . A fire clearance was approved on June 6, 2023 for (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The applicant is also requesting a hospice waiver to retain two (2) resident. The smoke alarms are hardwired and interconnected. There is a battery operated carbon monoxide detector installed in the hallway by the bedroom and another by the common area. The facility has three fire extinguishers, that were last serviced on 06/08/2023. One fire extinguisher is located by the kitchen, and the other in the hallway by the bedroom and the third is by the dining area. A tour of the physical plant was initiated at approximately 10:00 a.m. and the following was observed: KITCHEN: The facility has a Kitchen that is equipped with a refrigerator, microwave, stove, dishwasher and sink. There was an adequate supply of perishable and nonperishable food. Knives were observed locked in a lock box that will kept in a kitchen drawer. Under the sink cabinet was locked and cleaning supplies for the kitchen will be stored. BEDROOMS: There are six (6) bedrooms designated for client use. Bedrooms will be for private use. The applicant furnished the resident bedrooms with beds, night stand, chairs, dressers, bedding and linen. The bedrooms have sufficient lighting. Two out of the six bedrooms have built in shelves for storage. BATHROOMS: The facility has two (2) shared bathrooms and third bathroom designated for staff and visitors only. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water temperature in one of the shared bathrooms measured at between 105 and 120 degrees. (LIC809-C continued)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TERNER HEALTH	FACILITY NUMBER: 197610422
	VISIT DATE: 07/11/2023

NARRATIVE

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COMMON AREAS: These included the living room and the dining area. Living room was furnished with chairs and side tables. The dining area was furnished with a television, a large table and chairs to sit the capacity of the facility. There were no visible immediate hazards. Cleaning supplies and chemicals are stored and locked in a closet by the living room. LPA observed cameras throughout the facility directed at the common areas. LPA observed two telephone land lines accessible to residents in the living room.

LAUNDRY ROOM: The laundry room is located in the hallway by the bedroom. The room was locked inaccessible to residents. The laundry room had a washer and dryer.

MEDICATIONS: The medication cabinet will be maintained in the staff room/office. It has a locking mechanism.

Staff/Resident Records: Staff and resident records are maintained in a cabinet in the staff room/office. It has a locking mechanism.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a covered patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is a large field behind the patio that will be locked and inaccessible to residents. Side gate was checked to insure exit and passageways were clear of obstruction.

Component III conducted with the applicant. Administrator Emanuel Yazichyan was not present but has a record of participating in a Component III previously. Pre-licensing Inspection completed. No deficiencies were observed.

This report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. Report signed and delivered.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

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