197603560-6-30-2022-29-AS-JAPL-CHG38G-20220819180130

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603560
Report Date: 06/30/2022
Date Signed: 06/30/2022 10:47:37 AM

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
01/24/2022 and conducted by Evaluator Salia Walker

COMPLAINT CONTROL NUMBER: 29-AS-20220124092223

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:	06/30/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Evelina Papazyan, Administrator		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Staff forged facility records

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit to deliver the findings for the above allegation. The LPA met with Administrator Evelina Papazyan at 10:06 a.m., and explained the reason for the visit.

On 01/25/22, LPA Salia Walker arrived unannounced to conduct an initial complaint inspection for the above allegation(s). During the visit, the LPA conducted a physical plant tour at 10:23 a.m., briefly spoke with staff, conducted a file review, and obtained copies of pertinent documentation. The Administrator was notified that this complaint was referred to Community Care Licensing Investigation's Branch (IB), and assigned to Investigator Jose Santana. The LPA determined further investigation was required before findings were delivered.

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: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

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-20220124092223

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: 06/30/2022

NARRATIVE

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On 05/24/22, LPA Walker conducted a subsequent complaint visit. Form 9:58 a.m. until 10:30 a.m., the LPA conducted an interview with the administrator. From 10:30 a.m. until 12:15 p.m., the LPA conducted interviews with facility staff. From 1:09 p.m. until 2:25 p.m., the LPA conducted telephone interviews. The LPA determined further investigation was required prior to issuing findings.

On 06/24/22, LPA Walker conducted a subsequent complaint visit. During the visit, the LPA conducted a physical plant tour with Administrator Evelina Papazyan at 10:16 a.m. From 10:30 a.m. until 1:17 p.m., the LPA conducted interviews with facility residents. The LPA determined further investigation was required prior to issuing findings.

Regarding the allegation, ‘Staff forged facility records,’ the complainant’s concern is that the Administrator is forging facility records by altering resident files such as their physicians’ reports.
During the investigation, LPA Walker conducted a record review, interviewed the Administrator, facility staff, residents, and credible sources.

To conduct a thorough investigation, the LPA interviewed residents and assessed their abilities in comparison to their physicians’ reports ensuring that their mental and physical abilities match what is on record. Record review confirmed that resident files were accurate, and no alterations, white outs, marks, or changes were found. An interview with the Administrator revealed that the Administrator is the person in charge of resident files. The interview also revealed that when a resident is relocated to the facility from another location, the previous business sends a copy of the resident’s recent physicians report. The Administrator also stated that ‘sometimes they fax it.’ The Administrator also stated that any changes to the physician’s reports are made only by the resident’s physician conducting the evaluation. Interviews with facility staff revealed that staff have ‘not observed any documents having white out, or alterations,’ and have ‘not observed the Administrator altering any documentation.’ Staff interviews also revealed that ‘documents usually come in a fax, or an email,’ and ‘then [staff] print copies for the files.’ Staff stated that ‘any changes that need to be made [staff] call the doctor,’ and advise of inaccuracies based on assessment.

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: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220124092223

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: 06/30/2022

NARRATIVE

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Interviews with credible sources revealed that Physicians conducting the medical assessments/ evaluations either fill out and sign the complete form themselves, or ‘discuss it with nurses, the nurses fill it out, and then [the physician] sign it.’ Interviews with credible sources also revealed that in-house physicians ‘first... do the physical, then... check the medication, and the history’ of the resident; and, if the residents can’t tell the physician their history, they review their medication to assess that resident. Interviews with credible sources revealed that some physicians have a personalized business stamp they utilize to avoid forgeries. Credible witnesses have not noted any white outs, marks, or alterations on resident’s physician reports and/or medical assessments.

Based on record review, and interviews which were conducted there is insufficient evidence to support the allegation ‘Staff forged facility records.’ 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: 06/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2022

LIC9099 (FAS) - (06/04)

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