197603560-7-6-2022-29-AS-JAPL-CHD3VG-20220816183507

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603560
Report Date: 07/06/2022
Date Signed: 07/06/2022 04:04:05 PM

Unsubstantiated

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
06/30/2022 and conducted by Evaluator Salia Walker

COMPLAINT CONTROL NUMBER: 29-AS-20220630155544

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: 76	DATE:	07/06/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Evelina Papazyan, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility will not accept resident back at facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for an initial complaint inspection for the above allegation. The LPA met with Administrator Evelina Papazyan at 9:50 a.m., and explained the reason for the visit.

During today’s visit, the LPA conducted a physical plant tour with the Administrator, Evelina Papazyan at 9:51 a.m. From 10:10 a.m. until 11:41 a.m., the LPA conducted an interview with the administrator. From 11:41 a.m. until 12:30 p.m., interviews were conducted with facility staff. From 12:30 p.m. until 1:00 p.m., the LPA reviewed and obtained copies of documents pertinent to the investigation. From 1:00 p.m. until 2:00 p.m., the LPA conducted telephone interviews with credible sources.

Continue on LIC9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

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-20220630155544

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: 07/06/2022

NARRATIVE

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Regarding the allegation, ‘Facility will not accept resident back at facility,’ the complainant’s concern is that on 6/29/2022 and 6/30/2022, hospital personnel called the facility staff to inform them that Resident #1 (R1) was ready to be discharged from the 5150 hold and the facility staff stated they would not accept R1 back to the facility, alleging that R1 checked themselves out of the facility with no intention of returning. The complainant is aware that R1 was not served with an eviction notice; and, that the facility staff gave R1 a check-out form which only states that all of R1’s property was given to R1 upon their discharge from the facility. However, they believed that the facility should still take R1 back, since this was R1’s last known place of residence.

An interview with the administrator revealed that on 06/26/22, Law Enforcement was contacted by the facility after R1 used an object which R1 identified as a ‘gun’ to make threats towards facility staff and residents. According to the Administrator, Law Enforcement did not arrest R1 as they confirmed that the object was not a firearm, though visually, it would be difficult to tell if it was a ‘real’ handgun or not. The interview with the Administrator also revealed that on 06/27/22, the facility contacted the Psychiatric Emergency Team (PET) when R1 began making verbal threats to staff once more, stating things such as “on 4th of July, real fireworks are going to happen.”

Interviews with facility staff revealed that on 06/27/22, after R1’s inappropriate behavior, two (2) PET team members arrived at the facility to assess R1; and, they determined R1 needed to be place on a 51/50 hold, which is the code for the temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness. Interviews with facility staff also revealed that on 06/27/22, the PET team advised the Administrator that R1 wanted to voluntarily go with them and that R1 “didn’t want to come back to the facility after,” and asked if staff could gather all of R1’s belongings per R1’s request.

LPA Walker conducted a record review, interviews with the Administrator, facility staff, and credible sources. The record review revealed that on 06/27/2022, R1 filled out and signed a ‘personal belongings removal form’ provided by the facility upon R1 requesting to ‘move out’ of the facility. The record review also revealed that on 06/27/22, R1 was placed on a voluntary 51/50 hold. The facility staff then discharged R1, as R1 removed all their belongings the same day.
Continue on LIC9099C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220630155544

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: 07/06/2022

NARRATIVE

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After a few days, R1 was ready to be discharged from the hospital. Interview(s) with credible sources revealed that R1 was an Assisted Living Waiver Program recipient and that staff from the Assisted Living Waiver Program was currently looking for an alternative placement for R1; and R1 is due to be discharged to R1’s new facility on 07/08/22. Interview(s) with credible witnesses also revealed that a Social Worker at the hospital stated to the ALW program coordinator that R1 can’t be released from the hospital until a placement has been found.

Based on record review, and interviews which were conducted, R1 requested to move out of the facility and removed their belongings voluntarily. As a result, the facility staff discharged R1 upon request. Therefore, the facility does not have any obligation to take R1 back into the facility. Furthermore, there is insufficient evidence to support the allegation ‘Facility will not accept resident back at facility.’ As a result, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted and a copy of the report was emailed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022

LIC9099 (FAS) - (06/04)

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