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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609655
Report Date: 01/23/2024
Date Signed: 01/23/2024 02:16:53 PM


Document Has Been Signed on 01/23/2024 02:16 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
WOODLAND HILLS S.RO, 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: 5DATE:
01/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mari Akmakchyan, Staff #1TIME COMPLETED:
02:50 PM
NARRATIVE
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At 10:00am, Licensing Program Analysts (LPAs) Huma Rahimi, Angela Panushkina, and Perchui Milena Khurshudyan conducted a Case Management Visit. LPAs met with the Staff # 1, Mari Akmakchyan and explained the reason for the visit.
  • During the visit, S1 informed LPAs that S2 started working at this facility on 01/08/2024. LPAs conducted review of Licensing Information System and did not observe S2's association to this facility. LPAs informed the S1 that all staff members must be fingerprint cleared and associated prior to employment.
  • Moreover, Administrators' Certificate on file has been expired and the facility does not currently have a back up Administrator.
  • LPAs observed that only three (3) out of five (5) residents facility files are missing documents/signatures (incomplete).
  • The facility is not approved to retain any bedridden resident; however, LPAs observed R2 and R3 were in bed and review of their Physician's Report indicated that they are both bed bound. Moreover, LPAs were informed that both residents are receiving Hospice Care (facility is currently approved for one (1) hospice waiver only). No Hospice files for R2 and R3 were available upon request. Lastly, LPAs observed R2 and R3 had full bed rail and no Physicians order on file.
  • LPAs observed that R1 is on a wheelchair. Facility License (Effective 03/18/2019) is APPROVED FOR CAPACITY OF 6 AMBULATORY; APPROVED FOR HOSPICE WAIVER FOR 1 HOSPICE RESIDENT.
  • The facility also failed to submit an Incident and Death Report for R6 to the Community Care Licensing Division (CCLD) in a timely manner. Based on Title 22 Regulation: a written Unusual Incident / Injury Report / Death Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed Administrator that all staff members are mandated reporters and they are all responsible for reporting.

Deficiency issued on LIC809-D
Exit interview conducted, appeal rights explained and copy of this report signed and delivered.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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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Document Has Been Signed on 01/23/2024 02:16 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: TNA RESIDENTIAL CARE
FACILITY NUMBER: 197609655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2024
Section Cited
CCR
87355(e)(1)

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Criminal record clearance: (e) All individuals subject to a criminal record review... (1) Obtain a California clearance or a criminal record exemption as required by the Department.
This requirement is not met as evidenced by:
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Licensee agreed to complete S2's fingerprints and associate the staff to the facility. Copy of proof will be submitted to LPA by POC date.

Civil penalty assessed.
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Based on interview and record review, the licensee did not comply with the section cited above by hiring one (1) staff member S2 on January 8th, 2024 without fingerprint clearance, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
01/24/2024
Section Cited
CCR87202(a)(2)

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Fire Clearance: (a) All facilities shall maintain a fire clearance approved... Prior to accepting or retaining any of the following types of persons... (2) Bedridden persons

This requirement is not met as evidenced by:
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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
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Based on interview and record review, the licensee did not comply with the section cited above by accepting two (2) bedridden residents (R2 and R3) without having a proper fire clearance, which poses an immediate health, safety or personal rights risk to persons 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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2024 02:16 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: TNA RESIDENTIAL CARE
FACILITY NUMBER: 197609655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2024
Section Cited
CCR
87406(g)

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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:
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Licensee agreed to renew the Administrator certificate and submit proof of enrolled classe to LPA by POC date.
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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.
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Type B
01/30/2024
Section Cited
CCR87506(a)

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87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...

This requirement is not met as evidenced by:
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Licensee agreed to complete three (3) out of five (5) resident files.
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Based on record review, the licensee did not comply with the section cited above. Three (3) resident records were incomplete and or missing documents, which poses/posed a potential health, safety or personal rights risk to persons 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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 01/23/2024 02:16 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: TNA RESIDENTIAL CARE
FACILITY NUMBER: 197609655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2024
Section Cited
CCR
87608(a)(3)

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Postural Supports: Based on the individual pre-admission apprasial... Postural support maybe used udner the following condition: 3) A written order from the Physician indication... licensing agency shall be authorized to require...
This requirement is not met as evidenced by:
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Licensee agreed to obtain a doctor order for two (2) half bed rails and two (2) hospice full rails. Copy of proof will be submitted to LPA
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Based on interview and record review, the licensee did not comply with the section cited above having two (2) full bed rail beds and two (2) half bed rail without a doctors approval, which poses an potential health, safety or personal rights risk to persons 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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2024 02:16 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: TNA RESIDENTIAL CARE
FACILITY NUMBER: 197609655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2024
Section Cited
CCR
87632(a)(1)

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87632 Hospice Care Waiver: (a) In order accept or retain terminally ill residents... To obtain this waiver the licensee shall submit a written request for a waiver to the Department...

This requirement is not met as evidenced by:
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Licensee agreed to submit a hospice exception for one (1) resident. Proof of the exception letter will be emailed to LPA by POC date.
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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.
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Type B
01/30/2024
Section Cited
CCR87211(a)(1)A,B&D

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Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...

This requirement is not met as evidenced by:
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Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Copies of two (2) incidents, shall be submitted to LPA by POC date.
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Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding the two (2) incidents that occured with R6, which poses a potential health and safety risk to persons 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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 01/23/2024 02:16 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: TNA RESIDENTIAL CARE
FACILITY NUMBER: 197609655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2024
Section Cited
CCR
87405(d)(1,2)

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Administrator Qualifications - 87405 (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator... (1) Knowledge of the requirements...
This requirement is not met as evidenced by:
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Licensee agrees to follow proper guidelines for Administrator Qualifications. LPA discussed with the administrators section 87405. Licensee agrees to submit a written letter to CCL indicating that they have read the regulations, have full understanding
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Based on interviews, the licensee failed to insure that the administrator had knowledge of licensing rules and regulations which poses an immediate health and safety risk to the 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: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma RahimiTELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6