197603560-11-1-2021-29-AS-ASMH-C8CPNB-20211101112739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603560
Report Date: 11/01/2021
Date Signed: 11/01/2021 11:28:05 AM

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: 71	DATE:	11/01/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Evelina Papazyan		TIME COMPLETED:	11:30 AM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator 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 dining room furniture was observed to be in good condition.

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

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms are sufficiently stocked with hand liquid soap and paper towels.

COMMON SPACES: Common areas include the dining room, activity room, library, theater room, and patio. 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 3/2021. Required postings were observed throughout the common hallways.

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.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

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: 11/01/2021

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INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) in storage and the facility is able to obtain additional supplies as needed. The LPA observed resident and staff temperature logs, visitation screening questions, and cleaning log. The facility’s cleaning protocol is sufficient. Staff and residents were observed wearing face coverings. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA and Administrator discussed the recent PIN as it relates to visitation and staff vaccination requirements. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. This facility keeps track of vaccination rates for current staff. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. Copies of the resident and staff roster were obtained for the file. A copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021

LIC809 (FAS) - (06/04)

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