197603560-12-2-2024-29-AS-EMOY-DBL3RZ-20241202172935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603560
Report Date: 12/02/2024
Date Signed: 12/02/2024 05:29:52 PM

Document Has Been Signed on 12/02/2024 05:29 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/ DIRECTOR:	EVELINA PAPAZYAN		FACILITY TYPE:	740
ADDRESS:	6951 LENNOX AVENUE		TELEPHONE:	(818) 780-5005
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 195	TOTAL ENROLLED CHILDREN: 0	CENSUS: 80	DATE:	12/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:55 AM
MET WITH:	Evelina Papazyan - Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:40 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) Erica Mosley arrived at the facility unannounced to conduct a required annual visit at 9:55 a.m. Upon arrival LPA was greeted by front desk receptionist and explained the reason for the visit. LPA met with Administrator, Evelina Papzyan and the reason for the visit was explained. At approx. 10:00 a.m. LPA Mosley along with Administrator conducted a tour of the physical plant to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was noted: Facility is a three -story residential building consisting of 30 bedrooms, a commercial kitchen, dining room, television room, lounge and a staff break room on the first floor. The second floor has 36 bedrooms, dining room, library and television room. 16 bedrooms out of the 36 bedrooms are designated for the dementia / memory care unit. The third floor has 37 bedrooms. The facility is fire cleared for 63 Ambulatory, 112 Non-ambulatory and 20 bedridden residents. Delayed egress is approved for the dementia unit. Hospice waiver for 4. LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced on 1/11/2024. The Administrator provided a fire alarm testing and inspection report done on 12/04/2023 where all smoke alarms and carbon monoxide detectors were tested and functioned properly. The facility has their upcoming inspection scheduled for this week. The last emergency disaster drill took place on 09/30/2024 and are conducted quarterly. LPA observed all required postings adjacent to the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors of the dementia /memory unit were tested and functioned properly at the time of visit. Activities observed on both units. (PAGE 1) Report Continued on LIC 809C PAGE 2...

Kasandra Lopez	TELEPHONE: (818) 596-4343
Erica Mosley	TELEPHONE: (747) 230-3909
	DATE: 12/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: 12/02/2024

NARRATIVE

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(PAGE 2) Report Continued from LIC 809 PAGE 1...
Kitchen: During the facility tour, at 10:09 am the kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents in the dining area. Knives are stored and inaccessible to residents. Refrigerator and food pantry were checked for proper labels and expiration dates.

Bedrooms: During today’s visit from approx. 10:00 am to 10:51am, LPA observed nine (9) randomly selected resident bedrooms, of which six (6) in Assisted Living and three (3) in Memory Care. First floor: RM#109, RM#111, RM#114, Second floor: RM# 204, RM#206, RM# 215, RM# 226, RM#230, and Third floor RM# 313. The resident bedrooms were properly furnished with at least one chair, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Restrooms: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water measured between 106.0 – 118.9 degrees Fahrenheit all within the required range.

Common Areas: These included the libraries, activity rooms, television rooms, and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces in the common area are all non- functional.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for residents and visitors.

Infection Control / Emergency disaster planning: During today’s visit LPA Mosley reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures as it pertains to infection control are adequate. An adequate amount of emergency supplies including food and water is stored in a storage room adjacent to the kitchen area.
Report Continued on LIC 809C PAGE 3...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 12/02/2024

NARRATIVE

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(PAGE 3) Report Continued from LIC 809C PAGE 2...

MEDICATION AUDIT:

LPA conducted a medication audit on five (5) randomly selected residents at approx. 2:45 p.m., The medications are centrally stored in the medication room located on the 1^st floor. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. No errors observed during review.

RECORDS:
Resident Records and Personnel records were reviewed from approx. 10:51 am – 1:30 pm. LPA Mosley reviewed Resident Records at approx. 10:51 a.m. Eight (8) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. At approx. 12:15 p.m. Eight (8) personnel files including the Administrators file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order at the time of the visit. LPA obtained the following documents during the visit LIC 500 Staff roster, Resident roster, and current liability insurance.

INTERVIEWS:
From approx. 3:00 p.m. - 4:45 p.m LPA conducted eight (8) staff interviews and eight (8) resident interviews during the visit. No concerns noted at this time.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

LIC809 (FAS) - (06/04)

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