197603560-1-3-2023-29-AS-JAPL-CMXVKX-20230110153104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603560
Report Date: 01/03/2023
Date Signed: 01/03/2023 12:40:41 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
05/11/2022 and conducted by Evaluator Sandra Urena

COMPLAINT CONTROL NUMBER: 29-AS-20220511110219

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: 70	DATE:	01/03/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Evelina Papsyan		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff failed to meet resident's medical needs (OT/PT were prescribed).
Staff failed to meet resident's medical needs (resident wants to see R1's physician as R1 states R1's medication gives R1 chest pain).

INVESTIGATION FINDINGS:

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On 01/03/2023 Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent unannounced visit to investigate the allegations listed above. LPA Urena arrived at the facility at 10:30 a.m., met with Administrator Evelina Papazyan, and explained the reason of the visit.

On 05/17/2022, Licensing Program Analyst (LPA) Salia Walker arrived unannounced for an initial complaint inspection for the above allegations. The LPA met with Administrator Evelina Papazyan at 9:20 a.m., and explained the reason for the visit. During the visit, the LPA conducted a physical plant tour with the administrator at 10:15 a.m., interviewed staff at 9:20 a.m., and 9:30 a.m.; reviewed and obtained copies of documents pertinent to the investigation; and interviewed residents at 11:45 a.m., 2:10 p.m., 2:22 p.m., 2:58 p.m., and 3:13 p.m. Further investigation is required prior to issuing findings.

Continues on LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

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 29-AS-20220511110219

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: 01/03/2023

NARRATIVE

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On the allegation that ‘Staff failed to meet resident’s medical needs for the OT/PT prescribed’, on 02/17/2022 LPA Walker interviewed R1 at 2:10 p.m. about needing or receiving occupational therapy (OT) or physical therapy (PT). The R1 stated that they never had OT or PT, that they had asked staff at another facility if they could get OT, but did not ask staff at Courtyard Plaza. Record review of R1’s Physician’s Report dated 02/04/2022 does not indicate that R1 needs to receive OT or PT. On 11/30/2022, LPA Urena attempted to interview the physician who signed the physicians report, but physician reported that they were unavailable. On 12/27/2022, LPA Urena contacted the physician who provided the Diagnosis Information in the Move In Record for Courtyard Plaza dated 02/08/2022. The physician stated that they would have to review R1’s medical records to provide more information about the need or recommendation for PT for R1. On 12/29/2022, LPA Urena contacted the physician a second time about R1’s medical record review, and the physician stated that they saw R1 twice during their stay at the facility. The last time the physician saw R1 was on 06/2022, and based on their physical assessment of R1, the physician stated that they had not recommended PT for R1. LPA Urena received R1’s medical records from physician’s office, and the record review confirmed the diagnosis, and medications orders as explained by the physician during the interview.

Based on the information obtained through record review and interviews, there is insufficient evidence to support the allegation that Staff failed to meet resident's medical needs (OT/PT were prescribed). Therefore, this allegation is deemed Unsubstantiated at this time.

On the allegation that ‘Staff failed to meet resident's medical needs (resident wants to see R1's physician as R1 states R1's medication gives R1 chest pain)’, on 02/17/2022, LPA Walker interviewed R1 about the allegation. R1 stated that they have never seen a doctor, and that the doctor comes to see them at the facility, and the doctor has prescribed their medication. Additionally, R1 stated, ‘I have not asked any staff here to see a doctor’. On 12/29/2022, LPA Urena interviewed the physician on record for R1. The interview revealed that R1 had not complained of any chest pain, consequently, the physician continued to prescribe the medications as stated in R1’s record. LPA Walker interviewed the administrator about their procedure to address residents’ medical emergencies, and any medication reactions.

Continues on LIC 9099C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220511110219

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: 01/03/2023

NARRATIVE

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The administrator stated that 'if any resident ever complains of chest pain, they would immediately call 9-1-1. If the resident needs their medication, and the facility is managing it, the facility reorders the medications at least 20 days prior to running out of the medicine. If the resident is managing their own medications, the residents would tell us, and the facility staff would call the residents’ doctor if they request it'. LPA Urena conducted additional record review - Medical Administration Record (MAR's) on 01/03/2023 for R1, the record review revealed that the medication being taken by R1 did not produce an adverse reaction.

Based on the information obtained through interviews, and record review, there is insufficient evidence to support the allegation that staff failed to meet resident’s medical needs. Therefore, this allegation is deemed Unsubstantiated at this time.

No citations were issued. Exit interview was conducted with the facilities representative. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

LIC9099 (FAS) - (06/04)

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