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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609655
Report Date: 07/07/2023
Date Signed: 07/07/2023 12:40:29 PM

Document Has Been Signed on 07/07/2023 12:40 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: 4DATE:
07/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mari Akmakchyan, Administrator TIME COMPLETED:
01:15 PM
NARRATIVE
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At 9:30am, Licensing Program Analyst (LPA) Angela Panushkina conducted a Case Management Visit in conjunction with the complaint #31-AS-20230630161933. LPA met with the Administrator explained the reason for the visit, and requested resident and staff roster.

R1 was admitted to this facility on August 2nd, 2022 and passed away on May 5th, 2023. LPA was informed that several incidents took place between 08/02/2022 to 05/05/2023 (R1 was in and out of the Hospital due to medical condition/diagnoses), and were not submitted to the Community Care Licensing Department (CCLD) in a timely manner. Based on Title 22 Regulation: a written Unusual Incident / Injury Report / Death Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed Administrator that all staff members are mandated reporters and they are all responsible for reporting.

Deficiency issued on LIC809-D


Exit interview conducted, appeal rights explained and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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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Document Has Been Signed on 07/07/2023 12:40 PM - It Cannot Be Edited


Created By: Angela Panushkina On 07/07/2023 at 11:31 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TNA RESIDENTIAL CARE
FACILITY NUMBER: 197609655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2023
Section Cited

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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...
This requirement is not met as evidenced by:
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Based on interviews and record reviews, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1s multiple visits to an Emergency Room/Hospital between 08/02/22 -05/05/23, which poses a potential health and safety risk to persons 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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023


LIC809 (FAS) - (06/04)
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