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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609655
Report Date: 07/26/2022
Date Signed: 07/26/2022 11:20:04 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
07/21/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220721123746
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:
07/26/2022
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Mary AkmakchyanTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff not wearing masks.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegation above. LPA met with the administrator and explained the reason for this visit.
LPA conducted a physical plant tour to ensure no immediate health and safety issues. LPA did not observe any health and safety issues.
It is alleged that when the facility has had visitors that staff did not wear mask or do any Covid-19 screening. During today's visit upon entry LPA's temperature was taken and LPA observed all staff to be wearing mask. Administrator stated that they did have a recent visitor and staff were not wearing mask but since then all staff have been wearing mask and covid-19 screening has been conducted with all visitors. Based on the information obtained through interviews this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal Rights explained. Copy of report issued.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
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-20220721123746
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: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by
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Administrator will have in-service training with all staff on Covid-19 Protocols. Copy of in-service sign in sheet will be provided to LPA by email by POC due date.
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Based on interviews conducted facility staff were not wearing mask at all times while providing care which posed a potential health and safety risk to all 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: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC9099 (FAS) - (06/04)
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