197609655-4-23-2024-31-AS-HRAI-D4M3BE-20240423180609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609655
Report Date: 04/23/2024
Date Signed: 04/23/2024 06:09:29 PM

Document Has Been Signed on 04/23/2024 06:09 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TNA RESIDENTIAL CARE		FACILITY NUMBER:	197609655
ADMINISTRATOR:	AKMAKCHYAN, MARI		FACILITY TYPE:	740
ADDRESS:	18627 LANARK STREET		TELEPHONE:	(818) 593-9292
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 6	DATE:	04/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	MARI AKMAKCHYAN, Staff		TIME COMPLETED:	04:30 PM

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At 10:00 AM, Licensing Program Analysts (LPAs), Huma Rahimi, and Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. Team was greeted by the staff, Mari Akmakchyan, who granted access to the facility. LPAs explained the reason for the visit.

This facility is licensed for the capacity of six (6) Ambulatory and one (1) Hospice residents.

Upon arrival, Mrs. Akmakchyan informed LPAs that the facility currently has six (6) residents, of which four (4) are Non-ambulatory and one (1) is Bedridden. LPAs were also informed that only one resident (1) is on Hospice.

At approximately, 10:10am team conducted a tour of the facility, and the following was observed:

Common Areas: The facility maintains a comfortable temperature at 71°F. The living room and dining area appeared clean and were properly furnished. No obstructions observed throughout the facility. The facility license was not posted and or available for review.

Kitchen: LPAs observed sufficient supplies of staple non-perishable for 1 week and perishable for 2 days. At 10:15am, LPAs observed resident medications in a kitchen cabinet and Clorox along with other chemicals and detergents under the kitchen sink were kept unlocked and accessible to residents. Moreover, all knives and sharps in the kitchen drawer were kept unlocked and accessible to residents in care. There is a fire extinguisher by the kitchen that was last purchased on 05/25/2023.

Bedrooms: There are three (3) bedrooms designated for residents use and have sufficient lighting. All bedrooms have appropriate bedding and linens. LPAs observed two (2) half rail beds in room #1 and only one resident had a doctor's order. Moreover, LPAs observed residents bed was blocking the emergency exit

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TNA RESIDENTIAL CARE	FACILITY NUMBER: 197609655
	VISIT DATE: 04/23/2024

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sliding door. In room #2, LPAs observed one (1) full rail bed and room #3 had two half rail beds, without physician's order on file. and one (1) full bed rail bed in room #3. Physician's order for half/full bed rails were not available upon request.

Outside areas: At approximately, 10:40am team toured the outside area of the facility. LPAs observed a clean covered patio and backyard furniture to accommodate the six (6) residents.

Laundry: Laundry room is located outside and during the walk though, LPAs observed the room was kept unlocked and accessible to residents in care. Cleaning supplies were not locked.

Resident Files: At 11:00am LPAs conducted resident and staff records review. The following was observed. Six (6) out of six (6) resident files were incomplete. Files were missing signatures and forms (such as Admission Agreement, Physician’s Report, Resident Preplacement, Appraisals/Reappraisal, List of personal property, ID Emergency Sheets, and Personal Rights. Resident appraisals that were in the file did not have services explained and were missing signatures from the resident, and or responsible party. Please see LIC858 included with this report.

Staff Files: The following was observed. The Administrator has not renewed her Administrators Certificate since 08-26-2020. There are no completed personnel records for all 3 staff members which include the administrator. All three (3) staff files were missing First Aid Certificate and Mrs. Akmakchyan had required training on file.

Medications review: At approximately, 12:30pm LPAs conducted a review of medication for residents in care. None of the six (6) residents had a completed centrally stored medication and destruction record. No First Aid Kit available for review.

Administrative: Annual fees are past due. Last notice was mailed 01-03-2024 due by 03-18-2024. Amount of $742 is due immediately. Infection control plan is due immediately. Plans were due June 2022. LPAs collected a copy of Liability Insurance and LIC500.

Deficiencies and civil penalty issued, see LIC809Ds.

Exit interview conducted, appeal rights explained and copy of report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TNA RESIDENTIAL CARE	FACILITY NUMBER: 197609655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(5)(B)

Postural Supports (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by admitting a non-hospice resident (R3) and providing a full bed rail, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee agreed to remove R3's bed rail immediately.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by leaving the kitched drawer, with knives and sharp objects, unlocked and accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care..
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee agreed to have an in-house training with all staff regarding the care for Dementia residents and keep the sharp objects locked at all times. Proof of training will be emailed to LPA by POC date.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TNA RESIDENTIAL CARE	FACILITY NUMBER: 197609655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.69(a)(2)

1569.69(a)(2) Other Provisions: (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having a proper training for the staff (former Administrator) prior to their employment, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee agreed to hire a licensed vendor and provide training to all current and future staff. Proof of training/certificate will be submitted to LPA by POC date.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TNA RESIDENTIAL CARE	FACILITY NUMBER: 197609655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by leaving medications and nutritional supplements or vitamins, unlocked and accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee agreed to conduct an in-house training with all staff regarding the care for Dementia residents and always keep medications and locked. Proof of training will be emailed to LPA by POC date.

Type A

Section Cited

HSC

1569.625(b)(1)

Other Provisions (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by not providing all required training for Mrs. Akmakchyan , (training is important due to the level of care for the clients) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee agreed to hire a licensed vendor and provide training to all staff members. Copy of proof will be submitted to LPA by POC date.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TNA RESIDENTIAL CARE	FACILITY NUMBER: 197609655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by accepting a bedridden resident (R3) without having a proper fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee must submit LIC200 along with the facility sketch by POC date. Immediate civil penalty will be assessed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TNA RESIDENTIAL CARE	FACILITY NUMBER: 197609655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports: Based on the individual pre-admission appraisal and subsequent changes to that appraisal the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for him/herself. Postural support may be used under the following condition: 3) A written order from the Physician indication the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. Three (3) out of six (6) residents have a half bed rail without a doctor's order, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	Licensee agreed to obtain a doctor order for three (3) half bed rails. Copy of proof will be submit it to LPA

Type B

Section Cited

CCR

87406(g)

Administrator Certification Requirements: (g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Faciity's Administrator certificate had been expired since August 2020, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	Licensee agreed to renew the Administrator certificate and submit proof of enrolled classe to LPA by POC date.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TNA RESIDENTIAL CARE	FACILITY NUMBER: 197609655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Resident records were incomplete and or missing documents, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	Licensee agreed to complete six (6) out of six (6) resident files.

Type B

Section Cited

CCR

87412(a)

Personnel Records: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Upon LPA's request Licensee/Administrator was unable to provide own facility records. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	Licensee agreed to have a individual file for each staff member along with the training certificate.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TNA RESIDENTIAL CARE	FACILITY NUMBER: 197609655
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87156(a)

(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by failiy and renew her licensing fees that were due in March 2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	Licensee agreed to make a full payment immediately. Proof of payment/confirmation will be emailed to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

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