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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197603560
Report Date: 06/04/2026
Date Signed: 06/04/2026 06:04:16 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
11/24/2025 and conducted by Evaluator Christine Yee
COMPLAINT CONTROL NUMBER: 29-AS-20251124083503
FACILITY NAME:COURTYARD PLAZAFACILITY NUMBER:
197603560
ADMINISTRATOR:EVELINA PAPAZYANFACILITY TYPE:
740
ADDRESS:6951 LENNOX AVENUETELEPHONE:
(818) 780-5005
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:195CENSUS: 89DATE:
06/04/2026
UNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Marilou Mendoz, AdministratorTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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1. Staff did not seek medical attention in a timely manner resulting in resident passing away.
2. Staff did not ensure resident's medical needs were being met.
3. Staff did not provide transportation for resident's doctor's appointments.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Yee conducted a subsequent complaint visit to conduct further investigation and to deliver the findings for the above allegations. LPA met with Marilou Mendoza, Administrator and explained the reason for the visit.

On the allegation: Staff did not seek medical attention in a timely manner resulting in resident passing away. On 11/24/2025, Community Care Licensing (CCL) received a complaint alleging a resident passed away due to the facility not seeking timely medical attention. The Department conducted an investigation. On 11/25/2025, from 9:09am to 5:00pm, Licensing Program Analysts (LPAs) Yee and Chochian conducted an unannounced complaint visit. During this visit, LPAs toured the facility, collected relevant documents


Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
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 7
Control Number 29-AS-20251124083503
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: 06/04/2026
NARRATIVE
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Page 2.

including Special Incident Reports with fax confirmations, and documents for Resident 1 (R1) and Resident 2 (R2). On 12/24/2025, at approximately 5:28 pm the Department conducted interviews with Designated Responsible Staff, Aaron Feingold; on 3/10/2026 at 2:24pm conducted interviews with Family 1 (F1); and on 3/13/2026, at 9:46 am conducted interview with former administrator Denise Gilroy. The Department attempted multiple times to interview former Staff 1 (S1), who was the staff directly involved when R1 went to the hospital. However, S1 did not show up to the interview location and did not answer additional attempts to contact them for interview.

R1’s facility file was reviewed, including home health records and Incident reports. Records provided that R1 had diagnoses of Anemia, End Stage Renal Disease, Type 2 Diabetes, and was on Dialysis. R1 did not have any cognitive conditions and is able to communicate. Per R1’s medical assessment and care plan, R1 requires assistance with dressing, grooming, showering, incontinence care, and medication management.

During the investigation, medical records from Valley Presbyterian Hospital and home health records from Savanna Home Care, Inc. were collected and reviewed. R1’s home health records confirmed that the resident was receiving skilled nursing visits every day, prior to being transferred to the hospital. The home health records also confirm that the resident developed a Stage 1 pressure injury on 10/10/2025, and R1 received a referral for wound care the same day. On 10/13/2025, the home health records updated that the wound had progressed to a Stage 2 pressure injury.

On 10/14/2025, R1 was transported to the hospital and arrived around 11:13am. Per the Incident Report, R1 complained of right leg pain and the Administrator called 9-1-1. Records indicate the “Dispatch Complaint” for R1 was a “Diabetic problem” and the chief complaint was altered mental status. Hospital records indicate R1’s sacrococcyx wound was “unstageable” on 10/14/2025 at 11:30pm. R1 was admitted to the hospital due to the altered mental status, bradycardia, and hyperkalemia. Medical records indicate R1 had a history of end-stage-renal disease, was blind, and previously had a stroke'


Continued on LIC9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20251124083503
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: 06/04/2026
NARRATIVE
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Hospital records state R1 was admitted to the intensive care unit for “ongoing management of sepsis.” R1 had a previous diagnosis that included “bloodstream infection due to central venous catheter,” “sepsis due to methicillin resistant Staphylococcus Aureus,” and “other toxic encephalopathy.” Records state “In 2023 the patient sustained a distal femur fracture treated with a retrograde intramedullary nail (since removed), followed by a subsequent left hip fracture stabilized with an antegrade trochanteric entry nail.” A surgical procedure was scheduled on 10/27/25 to “remove the infected hardware”, but R1 passed away on 10/27/25 at the hospital.

During the interview with F1, they stated “[R1] didn’t want to go” to the hospital, “[R1] was still conscious” and the facility staff had to make a “second request” to have R1 transported to the hospital. F1 stated “they called me twice” to advise F1 that they were attempting to send R1 to the hospital. F1 did not believe the facility was neglectful in R1’s care, and indicated they felt the facility did a good job at monitoring R1’s change in conditions. F1 confirmed R1 was not in good health.

During an interview with former Administrator Denise Gilroy, administrator stated they were present during the incident where R1 was sent to the hospital, and stated that Staff #1 (S1) caused a delay in R1 being sent to the hospital because S1 had failed to call 9-1-1, and instead called a private ambulance. Information received from the reporting party confirmed there was a delay in calling 9-1-1 despite R1 being unresponsive and having low blood pressure. Designated Responsible Staff Feingold also confirmed S1 called for non-emergent transportation for R1 instead of following 911 protocol. S1, former employee was not technically terminated by the facility, but employment ended due to “Job Abandonment” after they did not show up for work for three (3) consecutive days.
Based on the interviews and records reviewed, home health was attending to R1 on a daily basis, and the facility did ultimately seek medical attention for R1. There was insufficient evidence to prove that the untimely medical attention directly caused R1’s death. Although the allegation may have happened there is not a preponderance of evidence to prove the alleged violation occurred therefore the allegation is Unsubstantiated


Continued on LIC9099-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20251124083503
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: 06/04/2026
NARRATIVE
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Page 4.

at this time. The admitted lack of timely medical attention for R1 will be addressed on a separate case management visit.

On the allegations: Staff did not ensure resident's medical needs were being met and Staff did not provide transportation for resident's doctor's appointments. It was alleged R2 had a Stage 3 pressure injury that did not receive any medical attention, such as home health. In addition, no medical appointments with R2’s doctor or hospital visits occurred.

R2’s physician’s report indicates they are able to care for their own activities of daily living, administer their own medications, had on cognitive impairment, and are able to communicate their needs. Facility records indicate R2 was sent to the hospital on 11/12/2025 and 11/20/2025. LPA reviewed an incident report that stated on 11/20/2025, a Med Tech contacted R2’s Primary Care Physician regarding an “active wound” and was in need of Home Health. The facility did not receive a follow up call and sent R2 to the hospital for evaluation. Per review of hospital documents provided for R2's hospital visit on 11/12/25 hospital visit, R2 went to the hospital due to a fall that morning. R2 had sustained an elbow contusion and had to wear a sling. Hospital paperwork also indicated that R2 had also sustained a skin tear on the right hand and would need wound care for it to heal. Hospital documents do not refer to any pressure injuries. Per interviews with Staff, Resident #2 had a history of falls and would sustain skin tears. Resident #2 did not have pressure injuries. Resident #2 also has a history of cellulitis on the legs. The facility attempted to secure medical attention and Home Health once the wound was discovered. Once it was determined the Primary Care Physician was not responding quickly enough, the resident was sent to the hospital on 11/20/25 to have the wound evaluated because it looked infected. Although the allegation may have happened there is not a preponderance of evidence to prove the alleged violation occurred therefore the allegations that Staff did not ensure resident's medical needs were being met and Staff did not provide transportation for resident's doctor's appointments are Unsubstantiated at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
11/24/2025 and conducted by Evaluator Christine Yee
COMPLAINT CONTROL NUMBER: 29-AS-20251124083503

FACILITY NAME:COURTYARD PLAZAFACILITY NUMBER:
197603560
ADMINISTRATOR:EVELINA PAPAZYANFACILITY TYPE:
740
ADDRESS:6951 LENNOX AVENUETELEPHONE:
(818) 780-5005
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY:195CENSUS: 89DATE:
06/04/2026
UNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Marilou Mendoz, AdministratorTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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4. Staff did not ensure incident reports were properly reported.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Yee conducted a subsequent complaint visit to conduct further investigation and to deliver findings for the above allegation. LPA met with Marilou Mendoza and explained the reason for the visit. On 11/25/2025, from 9:09am to 5:00pm, Licensing Program Analysts (LPAs) Yee and Chochian conducted an unannounced complaint visit. During this visit, LPAs toured the facility, collected relevant documents including Special Incident Reports with fax confirmations, and documents for Resident 1 (R1) and Resident 2 (R2).

On the allegation: Staff did not ensure incident reports were properly reported. It was alleged incidents were not being reported appropriately to Licensing. LPA reviewed incident reports received from the facility. LPA observed in November 2025, nine (9) incident reports were sent late, beyond the required seven (7) day

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20251124083503
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: 06/04/2026
NARRATIVE
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Page 2.

time frame. Per review of Department records, no incident report was submitted for the hospitalization of
of Resident #1 on 10/14/25. Based on the information obtained, the allegation is deemed Substantiated at this time.

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


Exit interview was conducted, APPEALS RIGHTS were discussed and copy of report and appeal rights were provided
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20251124083503
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/11/2026
Section Cited
CCR
87211(a)(1)
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Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.....This requirement was not met evidenced by:
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Licensee will read Section 87211-Reporting Requirements and submit a signed written statement that the section was reviewed and understood by 6/11/26. Licensee will also complete an incident report (LIC624) for R21's 10/14/25 hospital visit and submit by 6/5/26.
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The facility did not report the incidents, noted in the complaint within the required time frame or have fax confirmation of reporting until 11/25/25. Also noted, the hospital visit for Resident #1 on 10/14/25 has not been reported as of today's visit.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7