197603560-12-7-2023-29-AS-CYEE-CYB6F4-20231207194543

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603560
Report Date: 12/07/2023
Date Signed: 12/07/2023 07:45:49 PM

Document Has Been Signed on 12/07/2023 07:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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: 93	DATE:	12/07/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Evelina Papzyan, Administrator		TIME COMPLETED:	07:50 PM

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	Licensing Program Analyst (LPA) Christine Yee conducted a subsequent visit to continue the required Annual Inspection initiated on 12/6/23 using the complete CARE Inspection Tool. LPA Yee conducted the visit with Evelina Papazyan, Administrator. On today's visit LPA Yee reviewed the following domains: Physical Plant/Environmental Safety, Disaster Preparedness and Residents with Special Health Needs. A tour of the physical plant, inside and outside was also conducted. The kitchen, dining room, lounge, television rooms, libraries were inspected and the following resident bedrooms were inspected: 104, 111, 114, 120, 126, 201, 206, 213, 220, 303, 310, 317, 332 and rooms in the Dementia Unit - 221, 226, 231, 236. Per tour of the physical plan the following were observed: the Kitchen had the appropriate equipment, cleaning solutions were stored under the table located by the kitchen sink. Sufficient perishables and non-perishable foods were observed, individual bottles of water were observed in the room used to store the emergency food. The dining room has plenty of sitting for all the residents to eat in one sitting. The lounge on the first floor has sufficient seating, The television room on the first floor and in memory care have plenty seating for residents. All the bedrooms inspected have the required bed, chair, lamp, night stand, closet and dresser except for rooms number 231 and room #236 are missing the dresser. Residents are using the desk drawers as dressers. Beds were observed with linens that the residents have chosen that they want to use. Extra linens were observed in the linen closet Blinds for the windows and sliding glass doors in bedrooms #104, #111, #126, #220, #221, 226 were observed missing slates or were broken.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COURTYARD PLAZA	FACILITY NUMBER: 197603560
	VISIT DATE: 12/07/2023

NARRATIVE

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each bedroom has its own bathroom equipped with a shower with a shower curtain, grab bars, a shower chair, non-skid mat, a toilet and a sink. Water temperature was tested in the rooms that were inspected and the water temperature was within 105 -120 degrees Fahrenheit except for the following rooms - bedroom #201 - 121.8, bedroom # 206 - 121.4 and bedroom #236 - 93.2 degrees Fahrenheit
Carbon monoxide detector were observed in the dining room, lounge, the snack room and in resident bedrooms.
Smoke detectors located in all the resident bedrooms were not tested since the facility was just inspected by the vendor contracted by the fire department on 12/4/23 and the facility passed inspection. Copy of the report was obtained.
Fire extinguishers last serviced on 3/16/23 were observed on each floor. Located on the first floor are 5 fire extinguishers, including the kitchen, five on the second floor and 4 on the third floor.
First Aid Kit and first aid manual was observed.
The door on bedroom #120 was observed warped and needs repair.
Ceiling in bedroom #201 observed with chipped paint and needs repair due to water damage.
The floor of the balcony outside the second floor library and the patio chair needs repair.
The carpeting stored in the courtyard needs to be removed,
The facility needs general cleaning and all discarded items stored by the dumpsters in the parking lot need to be removed.
all three dumpsters in the parking lot were observed left open and needs to be tightly sealed.

Due to time constraints, only Type A citations were issued on today's visit. A return visit will be conducted to issue Type B citations observed on today's visit

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8

Exit interview was conducted, Appeals Rights discussed and a copy was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/07/2023 07:45 PM - 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COURTYARD PLAZA	FACILITY NUMBER: 197603560
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C 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 per water temperature tested in bedroom #i201 read 121.8, bedroom # 206 read 121.4 and bedroom #236 read 93.2 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	Licensee will adjust the thermostat so that the hot water controls shall be maintained automatically to regulate the temperature of the hot water used by the residents to attain a temperature of not less than 105 degree Fahrenheit and not more than 120 degree Fahrenheit by 12/8/23.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

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