197609655-4-24-2024-31-AS-NGID-D4PPK8-20240426112240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609655
Report Date: 04/23/2024
Date Signed: 04/24/2024 09:49:52 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20230630161933

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
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mari Akmakchyan, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff was negligent while assisting resident(s) while transferring to/from bed.

INVESTIGATION FINDINGS:

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At 10:00am, Licensing Program Analysts (LPAs) Angela Panushkina and Huma Rahimi conducted an unannounced subsequent complaint visit to deliver final findings. LPAs met with the Administrator and explained the reason for the visit.

During the initial visit conducted on 07/07/2023, LPA Panushkina requested resident and staff roster. At approximately 10:10am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. At 10:30am, LPA requested copies of pertinent information which include, but not limited to Physician’s report, Hospital Discharge papers, etc., relevant to the investigation. Between 11:00am – 12:00pm, LPA conducted an interview with the Administrator, two (2) staff members and three (3) out of four (4) residents, who were able to communicate.

Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
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.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230630161933

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/23/2024

NARRATIVE

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Allegation: Staff was negligent while assisting resident(s) while transferring to/from bed.

It was alleged that S1 handled R1 roughly while being transferred in and out of bed. It was also alleged that S1 dropped R1 on the floor on 3 separate occasions while trying to transfer in and out of the wheelchair. To investigate this allegation, LPA conducted an interview with the Administrator and four (4) residents. Only one (1) out of four (4) residents was present during R1’s stay at this facility. Although interview with one (1) out of four (4) residents revealed that the staff never handled R1 in a rough manner nor did any falls occur, interview with the Administrator confirmed that S1 was a little bit on a rough side and several times S1 was told about changing his/her manners. However, Administrator denied ever witnessing or hearing about R1’s incidents of falling. Based on the information received, this allegation is Substantiated.

Deficiencies issued per Title 22.

Exit interview conducted appeal rights explained and copy of this report provided to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230630161933

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/30/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Personal Rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Corrected before the initial visit. Licensee/Administrator informed LPA that S1 was fired as of March 2023.
	8 9 10 11 12 13 14	Based on interviews conducted, licensee failed to comply with the section cited above by not providing a proper training to staff. S1 handled R1 in a rough manner, which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20230630161933

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:	DATE:	04/23/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mari Akmakchyan, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not keep resident(s) free from punishment, humiliation, intimidation, abuse or other acts of a punitive nature.
Staff did not provide adequate required incontinent care to resident(s).

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
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.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 31-AS-20230630161933

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/23/2024

NARRATIVE

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Allegation: Staff did not keep resident(s) free from punishment, humiliation, intimidation, abuse or other acts of a punitive nature.

It was alleged that S2 would yell and threaten to hit R1. To investigate this allegation, LPA conducted an interview with the Administrator, two (2) staff and three (3) out of four (4) residents, who were able to communicate. Interview with the Administrator revealed that S2 was an amazing caregiver and provided care to all residents with dignity and respect. Moreover, only one (1) out of four (4) residents was present during R1’s stay at this facility, who corroborated Administrator's statement. Interview with two new staff members revealed that all resident's personal rights are being respected. Lastly, three (3) out of four (4) residents interviewed expressed no concerns regarding the above allegation. Therefore, based on interviews this allegation is deemed Unsubstantiated at this time.

Allegation: Staff did not provide adequate required incontinent care to resident(s).

During the initial visit conducted on 07/07/23, LPA observed all residents wear clean clothes, groomed and well taken care of. Interview with the Administrator and two (2) staff members revealed that all residents are being changed every 2-3 hours or as needed. Three (3) out of four (4) residents interviewed expressed no concern regarding the above allegation. Therefore, based on LPA's observation and interviews conducted, this allegations is deemed Unsubstantiated.

Exit interview conducted appeal rights explained and copy of this report provided to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
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

LIC9099 (FAS) - (06/04)

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