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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609655
Report Date: 06/02/2023
Date Signed: 06/02/2023 01:20:16 PM


Document Has Been Signed on 06/02/2023 01:20 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: 3DATE:
06/02/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mari Akmakchyan TIME COMPLETED:
01:50 PM
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An unannounced Plan of Correction (POC) visit was conducted on this day by Licensing Program Analyst (LPA) Angela Panushkina. The purpose of this visit is to follow up on the Plan of Corrections (POCs) that were issued during an annual visit made on 05/23/2023. Entrance interview conducted with the Administrator.

At 10:05am, LPA conducted a physical plan tour with the Administrator and was informed that the R1 is currently on Hospice Care and R2 and R3 are receiving Home Health services. At 10:20am, LPA requested three (3) out of three (3) resident files. All files were observed to be incomplete and or missing forms: 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 signatures from the resident, and or responsible party. Please see LIC858 included with this report. In addition, Hospice and Home Health files are missing and or incomplete missing care plan, admissions, notes. LPA discussed

During the 05/23/23 visit, facility was cited for the following deficiencies. The Licensing Report issued on 05/23/23 gave notice to the licensee that failure to correct the violations within a specified length of time would result in civil penalties being issued. During this visit the Administrator was reminded again that the civil penalties will continue to accrue until the violations are properly corrected.

As of today's visit Plan of Correction have not been submitted. 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. Licensee did not submit a plan of correction, therefore a civil penalty has been issued in the amount of $300.00 dollars (05/30/23-06/02/23).

Exit interview conducted, appeal rights discussed and copy of this report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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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