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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603560
Report Date: 05/17/2022
Date Signed: 05/17/2022 04:41:22 PM


Document Has Been Signed on 05/17/2022 04:41 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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: 77DATE:
05/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Evelina Papazyan, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management-Deficiencies visit at the facility today due to deficiency observed during the investigation of complaint control # 29-AS-20220511110219.

At 10:27 a.m., During the physical plant tour with Administrator Evelina Papazyan, the LPA observed that the facility’s exit/ back door located in the dining room leading to the parking lot; contained a double action door latch. The Administrator advised the LPA that the reason for the latch is security purposes due to the location of the facility. The LPA advised the Administrator that exit doors are to have a single action latch allowing residents to egress in case of an emergency.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):


Exit interview conducted, today's reports and appeal rights were reviewed and issued. Civil penalties issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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Document Has Been Signed on 05/17/2022 04:41 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2022
Section Cited

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
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Based on observation, the licensee did not comply with the section cited above, as the exit/ back door leading to the parking lot contained a double action door latch, which poses an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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