197603560-9-23-2022-31-AS-CHAS-CC43AD-20220228170433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603560
Report Date: 01/20/2022
Date Signed: 09/23/2022 03:25:59 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2019 and conducted by Evaluator Yelena Avetisyan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20190419115127

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: 64	DATE:	01/20/2022
		UNANNOUNCED	TIME BEGAN:	05:40 PM
MET WITH:	Georgina Osuna - Med-Tech		TIME COMPLETED:	06:55 PM

ALLEGATION(S):

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Resident sustained a hip fracture due to a lack of care and supervision.

INVESTIGATION FINDINGS:

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**This is an amended report to issue a deficiency under the correct regulation section.** Licensing Program Analyst (LPA) Yelena Avetisyan completed a subsequent complaint visit on 01/20/2022 to deliver findings for the allegation above. The LPA met with Georgina Osuna - Med-Tech and explained the reason for the visit. LPA spoke with the administrator Evelina Papazyan via telephone and informed her the findings of the investigation. Ms. Papazyan designated Georgina to sign for the report.

Allegation: Resident sustained a hip fracture due to a lack of care and supervision.

To investigate this allegation, LPA Nino Santos completed an initial complaint visit and obtained documents from R1 file, staff files, and facility file on 4/22/19. LPA Michael Cava reviewed records on 12/26/19. Records included incident reports, medical assessments, appraisals, and staff training. The file review revealed that R1 had a history multiple falls and was unable to walk without assistance. File documentation stated that staff would provide full care with activities of daily living. LPM Maryjo Schnitzer interviewed Administrator Evelina Papazian on 3/5/20. It was reported that staff were trained on resident care needs including, but not limited to, Fall Precautions, Needs of the Elderly, and Techniques of Personal Care.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 31-AS-20190419115127

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: COURTYARD PLAZA	FACILITY NUMBER: 197603560
	VISIT DATE: 01/20/2022

NARRATIVE

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Investigations Branch (IB) Investigator Edward Hector conducted staff interviews on 2/14/20, 2/18/20, and 3/5/20. Staff interviews revealed that staff was present before and after the incident, but not at the time of the fall. Staff admitted to leaving R1 alone while assisting another resident. According to medical records, the fall resulted in a hip fracture. Incident reports submitted to the Woodland Hills North Regional Office confirmed the occurrence of a fall resulting in hip fracture. According to information obtained from staff interviews, file review, and incident report review, there is sufficient information to support the allegation that the resident sustained a hip fracture due to a lack of care and supervision. Therefore, this allegation is substantiated.

A $500 immediate civil penalty is assessed today for a violation resulting in injury to R1. The licensee/administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).

Exit interview conducted. Appeal rights given. A copy of the report was issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Yelena Avetisyan	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20190419115127

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: COURTYARD PLAZA	FACILITY NUMBER: 197603560
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 01/22/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4)...In addition to the rights listed… residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	licensee/Administrator will obtain vendorized training for staff on regulation 87468.2(a)(4). Verification of scheduled training with the credentials of the trainer will need to be submitted within 24 hours.
	8 9 10 11 12 13 14	Based on staff interviews, file review, and incident report review the licensee did not comply with the cited section by not providing proper care and supervision which resulted in R1 sustaining a hip fracture which posed an immediate health and safety and personal rights risk to R1.	8 9 10 11 12 13 14	Licensee/Administrator will submit verification of the the completed training by 2/4/2021
	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.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (818) 378-8120
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

LIC9099 (FAS) - (06/04)

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