197603560-11-30-2022-29-AS-ASMH-CLNRDB-20221130115540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603560
Report Date: 11/30/2022
Date Signed: 11/30/2022 11:56:31 AM

Document Has Been Signed on 11/30/2022 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
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: 72	DATE:	11/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Evelina Papazyan		TIME COMPLETED:	12:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 9:15 a.m. The LPA met with Evelina Papazyan and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The facility obtains food delivery on a regular basis. The menu was posted and the facility offers various options for the residents to choose from. The dining room furniture was observed to be in good condition.

BEDROOMS: The LPA observed randomly selected resident rooms, which were furnished appropriately with clean linens, furnishings and sufficient lighting.

RESTROOMS: Restrooms are sufficiently stocked with hand liquid soap and paper towels. Appropriate hand washing signs were observed in all common restrooms. Water temperature was taken on the first and third floor in the common restrooms. The hot water measured between 113.7 degrees and 114.5 degrees Fahrenheit. The common restrooms on the second floor were closed for construction, as the toilets were being replaced and walls were being re-painted.

COMMON SPACES: Common areas include the dining room, activity room, library, theater room, and patio. The activity calendar was posted in a common area. Activities are offered throughout the day. In the common areas, walls, flooring and furniture were checked for cleanliness and good condition. The fire extinguisher in the hallways were fully charged and was last serviced 2/2022. The emergency systems were checked in 11/2021 by the Los Angeles Fire Department and were deemed operational.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/30/2022

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At 9:38 a.m., the LPA observed that one (1) out of two (2) elevators was inoperable at the time of the visit; however, a work order was placed to repair the elevator. As stated, there was one working elevator for resident use. At 9:41 a.m., the LPA observed an unlocked supply closet, which stored painting supplies. In addition, painting supplies were stored outside of a resident room, as it was actively being painted. The Administrator was notified, and it was communicated that certain rooms were being remodeled at the time of the visit. These items were secured by the end of the visit.

The facility has a courtyard equipped with furniture for resident use. There is a fountain, yet it is drained of water. No additional bodies of water noted. There are laundry areas throughout the facility for resident use.

INFECTION CONTROL: There was a central entry point for screening and temperature checks. The LPA was appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. Infection Control signs were observed at the entrance and throughout the facility. Hand sanitizer was available for resident and staff use. The facility’s cleaning protocol was sufficient. There was record of staff and resident vaccinations, along with record of COVID screenings for staff, residents, and visitors. The LPA discussed changes around testing, visitation and vaccine requirements. At this time, the Administrator continues to conduct surveillance testing of all staff and residents on a bi-weekly basis. The facility's procedures as it pertains to infection control are adequate.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Today's reports and appeal rights were reviewed and issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/30/2022 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as painting supplies were accessible in an unlocked storage closet and in the hallway, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 11/30/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to do the following: 1. The items were secured during the visit. Plan of Correction met at this time.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

LIC809 (FAS) - (06/04)

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