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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609655
Report Date: 02/22/2022
Date Signed: 02/22/2022 04:57:14 PM


Document Has Been Signed on 02/22/2022 04:57 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:TNA RESIDENTIAL CAREFACILITY NUMBER:
197609655
ADMINISTRATOR:AKMAKCHYAN, MARIFACILITY TYPE:
740
ADDRESS:18627 LANARK STREETTELEPHONE:
(818) 593-9292
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 3DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Jasmin BaklachanTIME COMPLETED:
05:15 PM
NARRATIVE
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At approximately 2:50 PM on 02/22/22, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit.

Census: 3

Entry: The facility was surrounded by a locked gate which was controlled by remote. The facility used surveillance cameras inside and outside. The front yard was well maintained.

Screening: LPA was screened upon entry for temperature, but not symptoms. LPA recorded temperature and contact tracing information in a visitor log. LPA advised Administrator to screen visitors for symptoms of COVID-19.

Bedrooms: The facility had 3 bedrooms. All bedrooms were designated for ambulatory residents. Bedroom #1, near the rear of the facility, had a non-ambulatory resident. Bedroom #2 was a shared bedroom with beds at least 6 feet apart to maintain physical distance. Bedroom #3 was also shared but unoccupied. All bedrooms contained adequate linens, storage space, nightstands, and lamps. All window screens were in good condition.

Bathrooms: The facility had 2 bathrooms. Bathroom #1 had liquid soap, paper towels, a handwashing instruction sign, a trash can with a tight-fitting lid, grab bars in the tub and toilet, and a non-skid mat. The knob for the sink faucet would not adjust water temperature. LPA could not test for hot water. LPA observed medicine below the sink and behind the mirror. Bathroom #2 had liquid soap, a handwashing instruction sign, and grab bars in the tub. There was a mount for grab bar near the toilet, but no grab bar. LPA tested water temperature at 126.8 degrees Fahrenheit.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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: TNA RESIDENTIAL CARE
FACILITY NUMBER: 197609655
VISIT DATE: 02/22/2022
NARRATIVE
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Common areas: LPA observed common areas to be organized, clean, and free from hazards. A metal grate covered a fireplace by the front entrance. LPA tested the smoke detector which was in good operation. Emergency Exit plans with routes clearly labeled were hung in the living room and resident bedrooms. LPA observed a fully-charged fire extinguisher hung near the kitchen. LPA also observed signs for resident rights, house rules, and a confidential complaint hotline. A staff bed was set up between the living room and the emergency exit.

Kitchen: LPA observed a dining table and a kitchen in good condition. All sharps and hazards were locked in cabinets. The facility had a sign pertaining to COVID-19 practices.

Outdoor area: LPA observed all exit routes to be free from hazards and obstructions. LPA observed 3 sheds outside. Two unlocked sheds contained incontinence supplies and patio furniture in good repair. A locked shed contained tools. LPA also observed a shaded swinging bench.

Due to the Administrator’s absence and staff’s limited English, LPA will return on a later date for a Continuation visit.

LPA conducted exit interview, issued deficiencies, discussed appeal rights, and issued report.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/22/2022 04:57 PM - It Cannot Be Edited

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: TNA RESIDENTIAL CARE
FACILITY NUMBER: 197609655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2022
Section Cited

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87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(6) Toilet, handwashing and bathing facilities shall be maintained in operating condition.

This requirement was not met as evidenced by:
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Based on observation, the Licensee did not maintain the knob to the faucet in operating condition in 1 out of 2 bathrooms. This posed a potential health and safety risk to residents in care.
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Type B
03/24/2022
Section Cited

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87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(4) Grab bars shall be maintained for each toilet; bathtub and shower used by residents.

This requirement was not met as evidenced by:
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Based on observation, the Licensee did not provide grab bars for 1 out of 2 toilets. This posed a potential health and safety risk to residents in care.
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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 02/22/2022 04:57 PM - It Cannot Be Edited

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: TNA RESIDENTIAL CARE
FACILITY NUMBER: 197609655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/23/2022
Section Cited

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87204 Limitations - Capacity and Ambulatory Status (b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents.

This requirement was not met as evidenced by:
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Based on observation and interview, it was determined a non-ambulatory resident stayed in a room designated for ambulatory residents. This posed an immediate health and safety risk for residents in care.
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Type A
02/23/2022
Section Cited

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87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) ... a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement was not met as evidenced by:
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Based on observation, the water temperature in 2 out of 2 bathrooms was not maintained within the required range. This posed an immediate health and safety risk to residents in care.
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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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4