197603560-9-27-2024-29-AS-KHEN-D9LT6Q-20240930142732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603560
Report Date: 09/27/2024
Date Signed: 09/27/2024 02:59:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
04/05/2024 and conducted by Evaluator Christine Yee

COMPLAINT CONTROL NUMBER: 29-AS-20240405104805

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: 80	DATE:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:			TIME COMPLETED:	03:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Food Service - food poisoning

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced subsequent complaint visit to deliver the findings of the above allegation and met with Evelina Papazyan, Administrator. The reason for the visit was provided.

LPA Yee conducted an initial unannounced complaint visit on 4/9/24. On the initial visit, LPA Yee conducted an interview with Evelina Papazyan, Administrator at 1:47pm, Staff #3 at 4:09pm, Resident #1 at 2:59pm, reviewed and obtained copies of Resident #1's file at 1:35pm and other facility documents throughout the visit. A tour of the kitchen was conducted at 3:50pm to observe the Ecolab chemical dish washing system in place to wash and disinfect the dishes, utensils, pots and pans.

Per information received from the interviews conducted, Resident #1 was taken to the hospital on 2/23/24 due to persistent diarrhea and vomiting. The resident believed that they have food poisoning

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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-20240405104805

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/27/2024

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

due to the dirty pots and pans in the facility. Per review of hospital documents, Resident was seen by the doctor for diarrhea and Enteritis (Bowel condition). Various lab tests were completed, including a CT scan of the abdomen and pelvis during this visit. Prescription for antibiotics, Cefpodoxime 200 mg and Metronidazole 500 mg, were prescribe for diarrhea and pneumonia at time of discharge. Per review of the discharge reports, one of the impressions noted by the reviewing doctor reveals that there “is fluid in the small bowel, colon, and rectum, consistent with enterocolitis/diarrhea” Diarrhea and vomiting are 2 of the common symptoms of enterocolitis. Enterocolitis may be caused by various infections including food poisoning. The meals consumed by Resident #1, were also consumed by other residents and no complaints of food poisoning were received.

Per interviews conducted with the Administrator and Staff #3, they have not received any complaints from the residents of food poisoning or aware of anyone who had food poisoning. Residents have had symptoms of diarrhea and vomiting at the facility when they had a Covid outbreak. It was not due to food poisoning. The Covid outbreak was reported to the Department on 2/12/24.

The kitchen was also toured together with the Administrator. It was observed that the facility has a Ecolab chemical dish washing system in place to wash and disinfect the dishes, utensils, pots and pans. Per information provided, the dishes, utensils, pots and pans are first pre-washed with chemicals, washed and then disinfected. Kitchen staff are trained to use the system to ensure that everything is washed and sanitized correctly.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20240405104805

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/27/2024

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

Based on the interviews and documents reviewed during the investigation, there is insufficient evidence to support the allegation that the resident had food poisoning as a result of the dirty pots and pans used for cooking, therefore the allegation is unsubstantiated at this time.

No deficiencies were cited on today's visit.

Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Christine Yee	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3