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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603560
Report Date: 07/13/2022
Date Signed: 07/13/2022 04:14:47 PM


Document Has Been Signed on 07/13/2022 04:14 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: 76DATE:
07/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Evelina Papazyan, AdministratorTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Salia Walker and Sandra Urena conducted an unannounced Case Management-Deficiencies visit at the facility today, due to deficiencies observed during the investigation of complaint control #29-AS-20220708115334. The LPAs met with Administrator Evelina Papazyan at 9:10 a.m. Entrance interview conducted.

From 9:16 a.m. until 10:40 a.m.; and from 2:00 p.m. until 3:00 p.m., LPAs Walker, Urena, and Administrator Evelina Papazyan conducted a physical plant tour. During the physical plant tour, a random selection of ten (10) resident rooms were inspected. At 9:46 a.m., LPA Walker was advised by Resident #1 (R1) that the facility hot water temperatures were elevated. Five (5) out of ten (10) resident rooms hot water temperatures measure between 121.7 and 129.5 degrees Fahrenheit. The LPAs advised the Administrator faucets used by residents for personal care shall maintain hot water temperatures of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). The Administrator acknowledged.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted. A copy of the report, and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-326-5838
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
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 07/13/2022 04:14 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: 07/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2022
Section Cited

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87303(e)(2) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets.. shall deliver.. hot water.. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
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Based on LPAs observation, the licensee failed to ensure hot water temperature measured within 105 to 120 degrees F in resident rooms 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: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
LIC809 (FAS) - (06/04)
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