197609655-5-23-2023-31-AS-APAA-CS52GR-20230523172334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609655
Report Date: 05/23/2023
Date Signed: 05/23/2023 05:24:32 PM

Document Has Been Signed on 05/23/2023 05:24 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 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: 4	DATE:	05/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Mari Akmakchyan, Administrator		TIME COMPLETED:	05:40 PM

NARRATIVE

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At 08:40am Licensing Program Analyst (LPA), Angela Panushkina and Licensing Program Manager (LPM) Nichelle Gillyard, conducted an unannounced annual inspection at the facility mentioned above. Team was greeted by the staff, Sairakul Bolosheva who granted access to the facility. Administrator was present and team explained the reason for the visit.

Team was informed that the facility currently has four (4) residents, of which three (3) resident are non-ambulatory and one (1) bedridden. Two residents are on hospice and 2 are receiving Home Health. Facility is approved for 1 hospice however has 2 hospice residents.

Resident Files: At 8:55am team conducted resident and staff records review. The following was observed. Four(4) out of 4 resident file were either not available and or incomplete. Files were missing signed and completed Admissions agreements, physician’s reports, resident preplacement appraisals/resident 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 signatured from the resident, and or responsible party. Please see LIC858 included with this report. Hospice and Home Health files are missing and or incomplete missing care plan, admissions, notes.

Staff Files: The following was observed. There are 2 staff working for at least a month without fingerprint clearance and or association to the facility. 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 files were missing personnel records(LIC501), Health Screening/TB results (LIC503), Criminal Record Statements (LIC508), Documented medications and general training not completed. Please see LIC859 included with this report.

At approximately, 9:35am team conducted a tour of the facility, and the following was observed:

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/23/2023

NARRATIVE

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Kitchen: Team observed sufficient supplies of staple non-perishable for 1 week and perishable for 2 days. Residents regular cycled medications was centrally stored in a cabinet in the kitchen. The medications were maintained closed by a mechanism which an individual can easily open. Team observed medication stored in the refrigerator belonging to previous resident, by the eggs. Medication was unlocked and accessible to residents. All knives and sharps in the kitchen drawer were kept unlocked and accessible to residents in care. In addition, Team observed Clorox along with other chemicals and detergents under the kitchen sink were kept unlocked and accessible to residents. There is a fire extinguisher by the kitchen and LPA was unable to verify the service/purchase date, however, the arrow on a meter was still on a green area, indicating that it was fully charged. Smoke alarm is operational however the carbon monoxide detector is inoperable.

Bedrooms: There are three (3) bedrooms designated for residents use and have sufficient lighting. All bedrooms have appropriate bedding and linens. Team observed two (2) half rail beds in room #1, One (1) half rail beds in room #2 and one (1) full bed rail bed in room #3. Physician's order for half/full bed rails were not available upon request. In addition, auditory alarm in bedroom #1 (exit door) was missing. Team also observed a folding bed (for the night shift staff) in the sunroom, by the exit door. LPA observed walls to be poorly scraped up in rooms 2/3 and paint around the door jamb is peeling away.

Bathrooms: At 10:15am team observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap, and paper towels. The hot water temperature measured at 122.6°F. LPA team observed appropriate grab bar and non-skid mat. Team also observed appropriate hand washing signs posted in each bathroom.

Common Areas: The facility maintains a comfortable temperature at 72°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. Personal Rights was not posted.

Outside areas: At approximately, 10:00am team toured the outside area of the facility. LPA team 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, LPA team observed the room was kept unlocked and accessible to residents in care. Cleaning supplies were not locked.
Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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
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: 05/23/2023

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: 05/25/2023
	Plan of Correction
1 2 3 4	Licensee agreed to complete and submit LIC200 along with the facility sketch to Fire Department for a Bedridden and non-ambulatory approval by POC date. Bedridden plan of operation and proof will be submitted to LPA Civil penalty issued

Type A

Section Cited

HSC

1569.311

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA team observation, the licensee did not comply with the section cited above to assure that the facility Carbon monoxide is operational, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Licensee agreed to purchase and replace a carbon monoxide by POC date. Copy of the receipt will be submitted to LPA

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: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 3 of 15

Document Has Been Signed on 05/23/2023 05:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 in hiring two (2) staff members in April 2023 and not providing required training, (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: 05/25/2023
	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) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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
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: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

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 providing a proper training to two staff members prior to their employment, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Licensee agreed to hire a licensed vendor and provide training to all current and furture staff. Proof of training/certificate will be submitted to LPA by POC date.

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 in by leaving various medications in a pre-pored box and not in their original container, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Licensee agreed to hire a licensed vendor and provide a centrally stored medication training to all staff. 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) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 5 of 15

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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
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: 05/23/2023

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 (R4) and providing a full bed rail without a doctors approval, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Licensee agreed to remove R4's bed rail immediately, and proof of picture will be submitted to LPA by POC date.

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: 05/25/2023
	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) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 6 of 15

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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
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: 05/23/2023

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: 05/25/2023
	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.

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) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 7 of 15

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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
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: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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. No staff records on file, no health screening/TB, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2023
	Plan of Correction
1 2 3 4	Licensee agreed to have all staff members shedule an appointment with their primary physician, complete health screening, including chest x-ray. Proof of health screening for two (2) staff members will be submitted to LPA

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: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

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
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: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

Criminal record clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or 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 hiring two (2) staff members (S1 and S2) in April 2023 without fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/25/2023
	Plan of Correction
1 2 3 4	Licensee agreed to complete S1's and S2's fingerprints and associate both staff members to the facility. Copy of proof will be submitted to LPA by POC date. Civil penalty 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) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 9 of 15

Document Has Been Signed on 05/23/2023 05:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87113

Posting requirements: The license shall be posted in a prominent location in the licensed facility accessible to public view 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. LPA did not observe license issued by the Department of Social Services being posted by the main entry door, which poses a potential health, safety risk to persons in care.
	POC Due Date: 05/30/2023
	Plan of Correction
1 2 3 4	Licensee agreed to post the facility license issued by the Department of Social Services by the entryway and proof of picture will be submitted 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) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 10 of 15

Document Has Been Signed on 05/23/2023 05:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/23/2023

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: 05/30/2023
	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.

Type B

Section Cited

CCR

87468(c)

Personal Rights: (c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. 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. LPA did not observe Personal Rights being posted in the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2023
	Plan of Correction
1 2 3 4	Licensee agreet to post all required personal rights and nondiscrimination notice in a public area by the entrance.

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: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 11 of 15

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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
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: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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: 05/30/2023
	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.

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) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 12 of 15

Document Has Been Signed on 05/23/2023 05:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports: Based on the individual pre-admission apprasial and subsequent changes to that appaisal the facility shall provide assistance and care for the residnet in those activities of daily living which the residnet is unable to do for him/herself. Postural support mayby used udner the following condition: 3) A written order from the Physician indication the need for the postural support shall be maintained in the residents record. The licensing agency shall be authorized to require othe 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 four (4) residents have a half bed rail without a doctor's odrer, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2023
	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 submitted to LPA

Type B

Section Cited

CCR

87632(a)(1)

87632 Hospice Care Waiver: (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. The request shall include, but not be limited to the following: (1) Specification of the maximum number of terminally ill residents which the facility wants to have at any one time. 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 addmiting two (2) hospice residents, when theh facility is only approved for one (1). This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2023
	Plan of Correction
1 2 3 4	Licensee agreed to submit a hospice exception for one (1) resident. Proof of the exception letter 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) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 13 of 15

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/23/2023

NARRATIVE

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Medications review: At approximately, 10:26 am team conducted a review of medication for residents in care. None of the 4 residents had a completed centrally stored medication and destruction record. Medications for R3 were observed to be pre-poured in a in a pill box for 3 days. No First Aid Kit available for review..

Administrative: Annual fees are past due. Last notice was mailed 01-04-2023 due by 03-18-2023. Amount of $742 is due immediately. The Administrator is required to submit liability insurance, LIC500 Personnel Report. Infection control plan is due immediately. Plans were due June 2022.

LPM informed the Administrator that a meeting will be requested in the near future to discuss the reason for continued non-compliance. LPA discuss the matter of a complaint in which the Administrator is running and unlicensed.

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) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

Page: 14 of 15

Document Has Been Signed on 05/23/2023 05:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

87506 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: 05/30/2023
	Plan of Correction
1 2 3 4	Licensee agreed to complete four (4) out of four (4) resident files.

Type B

Section Cited

CCR

87412(a)

87412 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 S1's and S2's facility records. LPA was informed that both staff members were hired in April 2023 and no file was completed. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2023
	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) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC809 (FAS) - (06/04)

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