197603560-10-6-2020-29-AS-JAPL-BU5W59-20201006165842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603560
Report Date: 10/06/2020
Date Signed: 10/06/2020 07:41:30 AM

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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2020 and conducted by Evaluator Aja Richardson

COMPLAINT CONTROL NUMBER: 29-AS-20200909141207

FACILITY NAME:	COURTYARD PLAZA		FACILITY NUMBER:	197603560
ADMINISTRATOR:	EVELINA PAPAZYAN		FACILITY TYPE:	740
ADDRESS:	6951 LENNOX AVENUE		TELEPHONE:	(818) 780-5005
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	195	CENSUS: 67	DATE:	10/06/2020
		UNANNOUNCED	TIME BEGAN:	07:33 AM
MET WITH:	Evelina Papazyan, Administrator		TIME COMPLETED:	07:34 AM

ALLEGATION(S):

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Facility is not adhering to the terms and conditions of the Admission Agreement.

INVESTIGATION FINDINGS:

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This report was initially issued on 9/24/2020. The 9099C did not attach and has been reissued on today's date.

Licensing Program Analyst (LPA) Aja RIchardson conducted a subsequent complaint visit for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Evelina Papazyan.
To investigate the above allegation, on 09/15/20 between 11 am and 2pm LPA conducted interviews with the facility Administrator, a witness, and an outside agency. On 9/24/20 at 9:45 am, LPA conducted an interview with R1 as well as reviewed R1's facility records including R1's admission's agreement. Based on the information obtained during the investigation R1 moved in on July 1, 2020, signed an admission agreement that stated R1 would live in and pay for a shared room. After the 14 day quarantine R1 and the Administrator had a conversation regarding moving another resident in the shared room.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

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 29-AS-20200909141207

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COURTYARD PLAZA	FACILITY NUMBER: 197603560
	VISIT DATE: 10/06/2020

NARRATIVE

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R1 does not agree that R1 should have a room mate during COVID-19 and the Administrator stated that based on the written agreement they can move another resident in the room. R1 stated the Administrator never threatened to evict R1 however they did not agree on the issue of moving a roommate in during COVID-19. Based on admission agreement signed by R1, this allegation is unsubstantiated at this time.

Exit Interview Conducted. Report emailed to Administrator.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

LIC9099 (FAS) - (06/04)

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