197603560-4-11-2022-29-AS-JAPL-CDLTDB-20220418143800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197603560
Report Date: 04/11/2022
Date Signed: 04/11/2022 11:13:04 AM

Unsubstantiated

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
11/30/2020 and conducted by Evaluator Salia Walker

COMPLAINT CONTROL NUMBER: 29-AS-20201130162840

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: 67	DATE:	04/11/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Evelina Papazyan, Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not seek timely medical care for resident

Illegal eviction

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint inspection for the above allegations. The LPA met with administrator Evelina Papazyan at 9:30 a.m., and explained the reason for the visit.

On 12/08/2020, LPA Aja Richardson initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted virtually with Administrator Evelina Papazyan. At 11:00 a.m., the LPA initiated the visit with the Administrator, and conducted interviews with the Administrator as well as requested Resident #1 (R1's) records. The LPA determined further investigation was needed at that time.

Continue on LIC9099C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

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 4

Control Number 29-AS-20201130162840

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: 04/11/2022

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

On 02/01/2022, LPA Walker conduct a subsequent complaint inspection for the above allegations. During the visit, the LPA conducted a physical plant tour with the administrator at 10:23 a.m., to ensure there were no health and safety hazards. From 10:50 a.m. until 12:40 p.m., the LPA conducted an interview with the administrator and obtained copies of documents pertinent to the investigation. From 12:45 p.m. until 1:13 p.m., the LPA conducted interviews with one (1) facility staff. The LPA determined further investigation was needed at that time.

During today’s visit, the LPA conducted a physical plant tour with the administrator Evelina Papazyan at 10:06 a.m., to ensure there are no health and safety hazards.

Regarding the allegation, ‘Staff did not seek timely medical care for resident,’ the complainant’s concern is that Resident #1 (R1) advised facility staff of being in excruciating pain at 2:30 a.m., and the staff did not call an ambulance until 7:30 a.m. to transport the resident to the hospital.

To conduct the investigation, LPA Walker previously conducted interviews with the administrator, facility staff, and a record review. The interview with the administrator revealed that facility staff contacted the administrator to advise that R1 requested to be transported to the hospital at “around 3:00 a.m.” The administrator stated that the staff called the ambulance, and noted the wait time would be 3 hours. The interview with the administrator also revealed that staff advised R1 of the wait time, and asked if R1 wanted staff to call 9-1-1 instead. According to the administrator, R1 refused due to 9-1-1 not transporting them to the hospital of choice on different occasions. To the administrator’s knowledge, the paramedics arrived between 6:45 a.m. and 7:00 a.m.

Interviews with staff revealed that R1 requested transportation to the hospital around 3:00 a.m., and staff called the paramedics. According to staff, the paramedics advised the wait time would be three (3) hours or more upon the initial call placed. According to staff, R1 was made aware of the wait time, but R1 wanted to wait to ensure they went to their preferred hospital. Interviews with staff also revealed that, they notified the administrator of incident due to concerns on “long wait time,” and was advised that resident’s personal rights allow R1 to deny services; and the facility needs to accommodate R1’s request.

Continue on LIC9099C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20201130162840

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: 04/11/2022

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

According staff, they continued to monitor R1, and asked if R1 would reconsider calling 9-1-1 instead. According to staff, R1 became upset, and continued to request to wait for the private paramedics which arrived “until after 6:00 a.m.” Record review revealed that R1 stated, “they told me it took that long to get an ambulance out there.” Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) during that time paramedics response times were delaying. However, the facility did contact paramedics immediately, and advised R1 of the arrival wait time. After receiving the complaint in November of 2020, R1 choose to move to another facility on 01/29/22. On 01/25/22, LPA Walker attempted to interview R1 at their new home, but R1 refused the interview and requested that they not be bothered.

Based on record review, interviews with the administrator, and staff, the facility did seek timely medical care for R1. Therefore, there is insufficient evidence to support the allegation ‘Staff did not seek timely medical care for resident.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

Regarding the allegation, ‘Illegal eviction,’ the complainant’s concern is that the facility refused to take the resident back after being discharged from the Hospital.

During the investigation, the LPA Richardson and LPA Walker conducted interviews with the administrator, and facility staff. Interview with the administrator revealed that on 11/28/20, R1’s case manager called the Administrator twice. According to the administrator, with the first call, the facility requested the hospital to send someone to train facility staff on how to properly change R1’s newly place medical device, an indwelling urinary Foley catheter placed greater than 2000 L drain. According to the administrator, the second call R1’s case manager confirmed they were going send a nurse to train the facility staff, but it would take about 48 hours to get someone out there. The administrator stated that at 7:00 p.m. they called the case manager, to follow up on why R1 hadn’t returned to the facility after 2 hours. According to the administrator, they were advised that the hospital did an assessment of the resident and determined R1 needed to be placed in a skilled nursing facility (SNF) for a few weeks prior to returning to the facility. The Administrator was not updated that R1 was not returning to the facility.

Continue on LIC9099C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20201130162840

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: 04/11/2022

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

An interview with the administrator revealed that the administrator later found that R1 was relocated to another board and care facility, and not a SNF. According to the administrator, they contacted the individual that arranged the transfer to inquire as to why R1 was relocated without proper discharge paperwork; and, to have the resident returned to their home at the above facility if R1 was willing to return. The administrator confirmed that R1 returned to the facility on 12/1/2020. Interviews with facility staff revealed that R1 returned to the facility with a catheter after being hospitalized on 11/28/20. A record review also revealed that R1 did return to the facility after being hospitalized on 11/28/20, and was not unlawfully evicted.

Based on a record review, interviews with the administrator, and facility staff, R1 was not unlawfully evicted, as R1 did return to the facility after being discharged from the hospital. Therefore, there is insufficient evidence to support the allegation ‘Illegal eviction.’ Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted and a copy of the report was emailed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4