<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603560
Report Date: 04/14/2023
Date Signed: 04/17/2023 09:43:35 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
07/08/2022 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20220708115334
FACILITY NAME:COURTYARD PLAZAFACILITY NUMBER:
197603560
ADMINISTRATOR:EVELINA PAPAZYANFACILITY TYPE:
740
ADDRESS:6951 LENNOX AVENUETELEPHONE:
(818) 780-5005
CITY:VAN NUYSSTATE: ZIP CODE:
91405
CAPACITY:195CENSUS: 85DATE:
04/14/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Evelina PapazyanTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to ensure residents are regularly observed for changes in physical, mental, and social functioning; Staff failed to assist residents with the self-administration of medication; Staff failed to ensure residents are adequately hydrated; Staff failed to ensure that facility was in good repair at all times; Staff failed to ensure that modified or prescribed diets were provided; Staff failed to ensure that the facility was clean and sanitary.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced a subsequent complaint visit at 9:30 a.m. to investigate and deliver the findings for the above allegations. The LPA met with facility representative Evelina Papazyan, and explained the reason for the visit.
On 07/13/2022, Licensing Program Analysts (LPAs) Salia Walker, and Sandra Urena conducted an unannounced visit at 8:30 a.m. to investigate the above allegations. The LPAs met with facility representative, Evelina Papazyan and explained the reason for the visit. The LPAs conducted record review, from 9:12 a.m. to 12:30 p.m. Toured the facility, and briefly spoke with staff, and residents from 9:19 a.m. to 12:30 p.m.; and from 2:00 p.m. to 3:00 p.m.
On 07/15/2022, Licensing Program Analysts (LPAs) Salia Walker, Sandra Urena, Ashley Smith, and Elsie Campos conducted a subsequent complaint visit at 10:10 a.m. to investigate the above allegations. The LPAs met with facility representative, Evelina Papazyan, and explained the reason for the visit. The LPAs interviewed staff at 10:45 a.m., and interviewed residents from 10:30 a.m. - 3:00 p.m. LPA Morgan interviewed the Administrator on 07/18/2022, at 10:45 a.m.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
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 7
Control Number 29-AS-20220708115334
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: 04/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff failed to ensure residents are regularly observed for changes in physical, mental, and social functioning.

On the allegation that ‘Staff failed to ensure residents are regularly observed for changes in physical, mental, and social functioning’ ; it is the concern of the complainant that R1 was not observed for changes in condition, resulting in R1 developing wounds all over the body and developing fungus in different part of the body as well. To investigate the allegation, LPA Urena reviewed R1’s file, Physician Report, Incident Reports, and medical records. LPA Morgan interviewed the Administrator on 07/18/2022 at 10:45 a.m. The Physician’s Report revealed that R1 was observed to be able to ambulate with a walker, and able to manage all Activities of Daily Living (ADLs), all checked ‘yes’ for Capacity for Self-Care, including medication administration. An Incident Report dated 4/28/2022, indicates that R1’s Doctor requested to see R1 because R1 refuses to see the doctor. Doctor confirmed that R1 was diabetic and claimed that R1 needed to check their glucose daily. R1 allegedly claimed that they never took their medications as they did not believe in modern medicine. PCP explained the concerns and R1 allegedly communicated understanding and reiterated that they did not believe in modern medicine.

On 4/28/2022, physician saw resident, and the physical examination revealed that R1 had fungus on their nails, but R1 refused to follow the doctor’s orders. R1 is ‘anti-medication’; declined home health care, antibiotics, and fungal cream as suggested by the doctor. R1 is independent, handles all of their own ADLs, facility recommended resident to be seen by the podiatrist, and psychologist but resident shows no interest. An Appraisal/Needs and Services Plan dated 4/29/2022, indicates that R1 does not believe they need assistance with ADLs.

A review of a Risk Agreement (signed by R1 and Administrator on 3/18/2018) was noted to have the following: resident refuses to take medication, and doesn’t believe in modern medicine; resident orders food from the outside; resident understands complication and risks associated with not taking medication or following diet. Resident doesn’t believe they are diabetic. Resident’s doctor, and family are aware of her choice.

On an Incident Report dated 5/20/2022, R1 was observed to have fungus on their feet. It was reported to the resident, and the resident’s PCP. R1 was recommended to go to a SNF or hospital to get the fungus treated. Administrator assisted resident with placement, and resident was transferred to a Post-Acute Nursing Home.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20220708115334
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: 04/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 07/18/2022, LPA Morgan interviewed the Administrator, and the interview revealed that residents are checked daily, a couple of times a day, and stated, ‘It depends though, if a resident is incontinent then they are checked at least four times per shift and throughout the day, and on the residents needs too. But if they are independent and do not need services, we still do wellness checks. We check on them every meal to make sure they are ok, or the caregivers will check on them. If a resident needs care and refuses, we will do a new appraisal, I would contact the family, we would encourage them, but if I think they are putting themselves in a dangerous situation, we will think they need a higher level of care, and I put in a 30 day notice.

Based on the information obtained through record review, and interviews there is not sufficient evidence to support the allegation that Staff failed to ensure residents are regularly observed for changes in physical, mental, and social functioning. Therefore, this allegation is deemed Unsubstantiated at this time.

Staff failed to assist residents with the self-administration of medication.

On the allegation that ‘Staff failed to assist residents with the self-administration of medication’; it is the concern of the complainant that R1 was in need of medication for diabetes, however the administrator claimed that R1 was not in need of medication. To investigate the allegation, LPA Urena reviewed R1’s facility records, and Physician Report. The record review of the Resident Appraisal (dated 3/4/2022) revealed that R1 did not ‘believe’ in modern medicine and believes in holistic health, and wellness. Physician’s report indicates that R1 was diagnosed as diabetic. Incident report dated 04/28/2022 indicates that the physician conducted a visit to see R1 at the facility, and confirmed that R1 was diabetic, and claimed that R1 needed to check their glucose daily. R1 allegedly claimed that they never took their medications as they did not believe in modern medicine. Physician explained the concerns and R1 allegedly communicated understanding and reiterated that they did not believe in modern medicine. Physician gave treatment options, and R1 rapidly responded that they did not believe in treatment or modern medication and said they were aware of their rights as a resident. R1 ultimately refused treatment.

Based on the information obtained through record review, there is not sufficient evidence to support the allegation that staff failed to assist residents with the self-administration of medication. Therefore, this allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20220708115334
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: 04/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff failed to ensure residents are adequately hydrated.

On the allegation that ‘Staff failed to ensure residents are adequately hydrated’; it is the concern of the complainant that when R1 arrived at the medical office, R1 was observed to be severely dehydrated’; to investigate the allegation, LPA Urena interviewed residents, staff and administrator. The Administrator stated that residents are offered liquids throughout the day, in addition to the liquids(water, milk, juice, coffee) offered through their daily meals, and snacks. The staff stated that they offer liquids to residents throughout the day. The LPA observed on the day of the visit a water dispenser located, and readily available in the common area of the activity room. The LPA interviewed residents about their access to liquids, and if they felt they got enough liquids. Ten out of ten residents stated that they are offered juice, coffee, and milk during meals and water throughout the day, and they have access to water.

Based on the information obtained through record review, there is not sufficient evidence to support the allegation that staff failed to ensure residents are adequately hydrated. Therefore, this allegation is deemed Unsubstantiated at this time.

Staff failed to ensure that facility was in good repair at all times.



On the allegation that ‘Staff failed to ensure that facility was in good repair at all times’; it is the concern of the complainant that when R1’s responsible parties picked up R1’s personal belongings at the facility, they noticed the room to be ‘in need of repairs.’ To investigate the allegation, on 07/13/2022 and 07/18/202, LPAs Urena, and Walker conducted an inspection of the facilities’ physical plant, and interviewed residents, staff, and the administrator. The LPA’s inspected 20 of rooms, and the inspection revealed that eight out of ten rooms were observed to have minor repairs.

Eight (8) out of ten (10) residents’ interviews revealed that they did not need any repairs in their room. Two residents stated that they did need repairs, but that the repairs were being addressed already. The administrator’s interview revealed that if a resident has something that needs to be fixed, administrator puts in a request for maintenance in the maintenance log, and they have 24hrs to respond. Facility also has a corporate maintenance person who can come in, facility has different vendors for different things if the in- house maintenance person cannot fix it.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20220708115334
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: 04/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Some of the AC units are leaking. We call the AC company all the time and they take time to come. We contact them immediately as soon as it is reported. If they can fix it, they will take care of it. But if they need parts they have to order them. The LPA reviewed Maintenance Work Orders(MWO) logs dated between 04/22/2022 to 06/29/2022. The MWO logs revealed miscellaneous problems that needed to be fixed such as towel racks, broken door, broken lamp, etc. The log dates revealed that the time frame between the date the problem was reported, to the date of the completion of the repairs, was anywhere from one day to eleven days.

Based on the information obtained through interviews, recorded review, and physical plant inspection, the facility is indeed in need of repairs. However, based on the interviews and record review, the facility is making every effort to address the repairs in a timely manner. Therefore, this allegation is deemed Unsubstantiated at this time.

Staff failed to ensure that modified or prescribed diets were provided.


On the allegation that ‘Staff failed to ensure that modified or prescribed diets were provided’; it is the concern of the complainant that the R1’s diet needs were not being addressed. To investigate the allegation the LPAs conducted record review, and residents’ interviews and staff and administrator interviews. The record review of manus indicated that residents receive two menus( Regular menu and the Special Diet Menu) to choose meals from. Residents are free to choose whatever meal they want. Administrator stated that residents are encouraged to follow their diet needs and restrictions, however the residents have the right to choose whatever meal they want. The administrator stated R1 was diabetic, but R1 ate what they wanted. R1 ordered a lot of food from outside the facility, and sometimes from the facility. R1 would sometimes call the front desk and order from the menu. We offer healthy choices, but R1 would pick whatever they wanted, although we would encourage R1 to pick a healthy choice. But R1 also had a lot of groceries coming in from outside the facility. Record review revealed that residents are offered a variety meals from the healthy menu, and the regular menu every week.

Based on the information obtained through interviews, and record review, there is not sufficient evidence to support the allegation that Staff failed to ensure that modified or prescribed diets were provided. Therefore, this allegation is deemed Unsubstantiated at this time.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 29-AS-20220708115334
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: 04/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff failed to ensure that the facility was clean and sanitary.

On the allegation that ‘Staff failed to ensure that facility was clean and sanitary’; it is the concern of the complainant that when R1’s responsible parties picked up R1’s personal belongings at the facility, they noticed the room to be ‘filthy’ , no additional descriptive information was provided. To investigate the allegation, LPAs Urena and Walker conducted an inspection of the facilities’ physical plant. LPA’s conducted residents’ and staff interviews. The LPAs inspected 10 rooms, and the inspection revealed that 10 out of 10 rooms were observed to be in order, and in clean condition. Eight out of ten residents stated that their rooms are cleaned once a week.

Although this allegation may have happened, based on the information obtained through observation of the physical plant, and interviews, there is not sufficient evidence to support the allegation that staff failed to ensure that the facility was clean and sanitary. Therefore this allegation is deemed Unsubstantiated at this time.

Exit interview conducted with facility representative Evelina Papasyan. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7