<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609655
Report Date: 10/13/2025
Date Signed: 10/13/2025 02:25:37 PM

Document Has Been Signed on 10/13/2025 02:25 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/
DIRECTOR:		CHRISTINA GABUZYANFACILITY TYPE:
740
ADDRESS:18627 LANARK STREETTELEPHONE:
(818) 593-9292
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 6DATE:
10/13/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Mari Akmakchyan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Huma Rahimi and Lorena Casillas conducted a subsequent unannounced visit to the facility in conjunction with complaint control #31-AS-20250828113316. Upon arrival, LPAs met with Staff #1 (S1), who granted access to the facility. The Licensee was contacted by the LPAs and were informed that the Administrator would be unable to join LPAs due to an appointment. LPAs explained the purpose of the visit and the Licensee arrived shortly after at 11:15 AM.

On September 2, 2025, LPA Rahimi conducted an initial complaint visit and was informed that approximately the last week of June 2025, a former staff member allegedly restrained Resident #2 (R2) which caused discomfort and pain in the presence of a witness . LPA interviewed the witness, who confirmed that the former staff member did, in fact, restrain R2, causing R2 to experience pain. LPA was informed that it was reported to the Licensee and the staff member was immediately fired and is no longer working at the facility. However, no incident report was submitted to the Community Care Licensing Department (CCLD). LPA reviewed all incident reports submitted through CCLD internal system and did not observe an incident report regarding this particular incident with R2. In addition, during today's visit, the Licensee admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Licensee that all staff members are mandated reporters and they are all responsible for reporting.



LPAs informed the Licensee to submit an incident report that occurred on or before :
  • Last week of June, 2025. Continue on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
Document Has Been Signed on 10/13/2025 02:25 PM - It Cannot Be Edited


Created By: Huma Rahimi On 10/13/2025 at 11:17 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TNA RESIDENTIAL CARE
FACILITY NUMBER: 197609655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2025
Section Cited
CCR
87202(a)(2)

1
2
3
4
5
6
7
Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...(2) Bedridden persons...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to re-locate resident with bedridden and non-ambulatory status until the fire clearance is obtained and approved. Licensee will provide re-location information via e-mail by the POC due date (10/14/2025).
Civil penalty will be assessed.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with the section cited above by accepting a bedridden and non-ambulatory residents without having a proper fire clearance, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type A
10/14/2025
Section Cited
CCR87355(e)(2)

1
2
3
4
5
6
7
7355(e)(2) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline.
1
2
3
4
5
6
7
Licensee agreed to associate S2 to the facility. The Licensee will submit the proof of correction to LPA by POC due date.
Civil penalty assessed.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with the section cited above by hiring S2 on 10/12/2025 without association, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
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
VISIT DATE: 10/13/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

During today’s physical plant tour, LPAs observed one (1) resident to be bedridden and three (3) residents to be non ambulatory in bedrooms #1 and #3 respectively, despite the facility being licensed for six (6) ambulatory residents only. LPAs reviewed resident records and observed that R2 is bedridden and three (3) out of six (6) residents are non-ambulatory and two (2) out six (6) resident are ambulatory. LPAs spoke to the Licensee and explained the importance of abiding by fire clearance. LPAs also explained that the bedridden and non ambulatory residents would need to be relocated and are not allowed to return until the fire clearance is approved. Furthermore, it was explained to the licensee that only residents cleared on fire clearance are allowed. Moreover, LPAs were informed that Staff #2 (S2) has been working at this facility providing direct care and supervision for two (2) days. However, LPAs reviewed the online Guardian website as well as LIS and did not observe S2 being associated with the facility. LPAs also explained to the Licensee the importance of associating staff to the facility. Based on interviews, observations and records reviews citations and civil penalties will be issued.


Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.

Exit interview conducted, appeal rights and copy of report signed and delivered.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/13/2025 02:25 PM - It Cannot Be Edited


Created By: Huma Rahimi On 10/13/2025 at 12:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TNA RESIDENTIAL CARE
FACILITY NUMBER: 197609655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2025
Section Cited
CCR
87211(a)(1)A,B&D

1
2
3
4
5
6
7
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:
1
2
3
4
5
6
7
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. R2's incident report shall be submitted to LPA by POC date.
8
9
10
11
12
13
14
Based on interviews and record reviews, conducted by LPAs, the licensee did not comply with the section cited above by failing to notify CCLD regarding the staff restraining R2 in June, 2025, which caused discomfort and pain to R2. This poses a potential health and safety risk to persons 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2025


LIC809 (FAS) - (06/04)
Page: 5 of 5