197609655-8-11-2022-31-AS-NMAN-CHDJZM-20220817072947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609655
Report Date: 08/11/2022
Date Signed: 08/11/2022 03:15:58 PM

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
07/30/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20200730161647

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:	08/11/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Hasmik Baklajyan - Staff		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care

INVESTIGATION FINDINGS:

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This is an amendment of the licensing report originally issued on 04/23/22. This report is amended to change findings of the alleged allegation based on additional information received by the Community Care Licensing Office.

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to deliver the amended report. LPA met with the staff Hasmik Baklajyan and explained the reason for today’s visit.

It was alleged that Resident #1 (R1) was admitted to the hospital with multiple unstageable, stage 3 and stage 4 pressure injuries.

During the initial visit on 07/31/20 at 1:30 PM, then LPA Gillyard interviewed residents of the facility, requested and reviewed copies of facility records relevant to the investigation. (continued on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

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-20200730161647

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: 08/11/2022

NARRATIVE

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(continued from LIC 9099)

A review of medical records conducted by the LPA Tan on 03/12/22 at 9:30 AM, revealed that R1 had a surgery for a broken ankle on 06/03/20 and was discharged from the hospital on 06/09/20 to the facility with assigned Palliative services upon discharge. Prior to admission, R1 had an existing pressure injury on the heel due to surgery and Stage 2 pressure injury on coccyx. Palliative care nurses were treating pressure injuries on R1’s coccyx and other locations. Hospital record review however, revealed that on 07/18/22 at 10:02 PM, R1 was admitted to the hospital with wound infection and sepsis due to unstageable pressure injury of back covered by slough/eschar, stage 4 pressure injury at right heel and stage 2 ulcer of left foot.

Based on record review, R1 was admitted to the facility with stage 2 pressure injuries. While in care of the facility, between 06/09/20 and 07/08/20, pressure injuries developed into higher stages. Subsequently, R1 was hospitalized due to infected wounds and sepsis.

Based on interviews and record review, there is a sufficient information to support the allegation. Therefore, the allegation deemed substantiated at this time.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200730161647

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: 08/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/15/2022 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	Prohibited Health Condition (a) Persons who require health services for or have a health condition including, but not limited to, those specified below, shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Staff agreed to inform the Administrator to review regulations related to prohibited and restricted health conditions and send a written statement of understanding to CCL. Administrator and staff will complete a training on pressure injuries and proof of training will be sent to CCL on or before the POC date
	8 9 10 11 12 13 14	Based on record review, the licensee did not ensure that R1 was not retained with a Stage 3 or 4 pressure injury and received proper care/treatment of the pressure injury, which posed an immediate 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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022

LIC9099 (FAS) - (06/04)

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