197603560-4-22-2021-29-AS-JAPL-C2CNMX-20210423103554

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603560
Report Date: 04/22/2021
Date Signed: 04/22/2021 01:35:56 PM

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
04/19/2021 and conducted by Evaluator Aja Richardson

COMPLAINT CONTROL NUMBER: 29-AS-20210419162045

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: 71	DATE:	04/22/2021
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Evelina Papazyan, Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident sustained bruises while in care.
Resident sustained multiple falls

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Aja Richardson and Sandra Urena conducted an unannounced 10-day visit to investigate the above allegations. LPAs met with the Administrator Evelina Papazyan at 9:13 am and explained the reason for the visit.
Allegation #1: Resident sustained bruises while in care: There are concerns that due to facilty neglect resident sustained bruising. During today's visit, between the hours of 9:50 am to 11:03 am, LPA conducted interviews with the Administrator, Staff, and Resident #1 (R1) relative. At 11:15 am, LPA reviewed R1's facility file which included R1's physician report, needs and services plan, incident reports, and skin Integrity document. According to the interviews conducted, on 3/15/21, R1 was found outside on the side walk after lunch by staff. R1 was found on the the ground with bruising, blood on left side of face and scratches on hand and arm. Based on LPAs record review and interviews R1 was able to leave unassisted and would frequently leave to go on walks. According to the facilty staff and R1's relative that was the only fall that R1 had at the facility. R1's relative was immediately notified and 911 was called.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210419162045

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: 04/22/2021

NARRATIVE

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Upon return from the hospital the facility conducted a reappraisal and R1 was transferred to the memory care unit. On 4/6/2021, R1 returned to the hospital due to lethargy. Upon arrival, according to interviews, R1 did not have any bruises. However according to facility, on 4/9/21, when R1 was discharged from the hospital, R1 returned with bruising to left eye. Interviews conducted with hospital social worker on 4/20/21 at 11:25 am revealed there was no documentation that R1 sustained bruising at the hospital. At this time due to conflicting statements there is insufficient evidence that due to facility staff neglect that R1 sustained additional bruises after the 3/15/2021 fall. This allegation is Unsubstantiated at this time.

Allegation #2: Resident sustained multiple falls: There are concerns that due to facility neglect resident sustained multiple falls. During today's visit, between the hours of 9:50 am to 11:03 am, LPA conducted interviews with the Administrator, Staff, and Resident #1 (R1) relative. At 11:15 am, LPA reviewed R1's facility file which included R1's physician report, needs and services plan, incident reports, and Skin Integrity document. According to the interviews conducted, on 3/15/21, R1 was found outside on the side walk after lunch by staff. R1 was found on the the ground with bruising and blood on left side of face and scratches on hand and arm. Based on LPAs record review and interviews R1 was able to leave unassisted and would frequently leave to go on walks. According to the facility staff and R1's relative that was the only fall that R1 had at the facility. R1's relative was immediately notified and 911 was called. At this time based on record review and interviews the fall that occurred on 3/15/2021 is the only fall that R1 sustained. Therefore the allegation that R1 sustained multiple falls is Unsubstantiated at this time.

Exit interview conducted. The report was signed, however a copy of the signed report was emailed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021

LIC9099 (FAS) - (06/04)

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