<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603560
Report Date: 05/24/2022
Date Signed: 05/24/2022 05:05:26 PM

Document Has Been Signed on 05/24/2022 05:05 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:
05/24/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Evelina Papazyan, AdministratorTIME COMPLETED:
05:00 PM
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
Licensing Program Analyst (LPA) Salia Walker conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20220124092223). LPA Walker met with
Administrator Evelina Papazyan. The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation.

During the complaint investigation of complaint #29-AS-20220124092223, Investigator Santana observed the following deficiencies:

The facility was aware that R1’s pressure injuries were worsening, but did not have a level of care meeting to discuss the change of condition with the resident, staff, and home health agency.

R1’s Reappraisal was not updated to reflect the change of condition that R1’s pressure injuries were worsening and R1’s refusal to reposition self and follow the Home Health care plan.

Citations issued, exit interview conduct, copy of report and appeal rights issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/24/2022 05:05 PM - It Cannot Be Edited


Created By: Salia Walker On 05/24/2022 at 04:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COURTYARD PLAZA
FACILITY NUMBER: 197603560

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2022
Section Cited
CCR
87463(c)

1
2
3
4
5
6
7
87463(c) Reappraisals(c):The licensee shall arrange a meeting with… a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition…

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit a plan on how you will ensure level of care meetings are conducted in a timely manner when there is a change in resident condition. Submit to CCL by 05/31/22.
8
9
10
11
12
13
14
Based on records review and interviews, the licensee did not comply with the section cited above. Facility failed to have a level of care meeting to discuss R1’s change of condition when R1’s pressure injuries were worsening, and R1 was not compliant with Home Health care plan, which posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
05/31/2022
Section Cited
CCR87463(a)(3)

1
2
3
4
5
6
7
Reappraisals(a)The pre-admission appraisal shall be updated...as frequently as necessary to note significant changes…(3) Any illness, injury…or change in the health care needs... specified in Sections 87455(c) or 87615, Prohibited Health Conditions.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit a plan on how you will ensure level of care meetings are conducted in a timely manner when there is a change in resident condition. Submit to CCL by 05/31/22.
8
9
10
11
12
13
14
Based on records review and interviews, the licensee did not comply with the section cited above. Facility failed to update R1’s appraisal with change of condition when R1’s pressure injuries worsened, and R1 was not compliant with Home Health care plan, which posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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 Pfannenstiel
LICENSING EVALUATOR NAME:Salia Walker
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2