197603560-12-29-2025-29-AS-CYEE-DPU4CF-20251229175905

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603560
Report Date: 12/29/2025
Date Signed: 12/29/2025 06:05:35 PM

Document Has Been Signed on 12/29/2025 06:05 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COURTYARD PLAZA		FACILITY NUMBER:	197603560
ADMINISTRATOR/ DIRECTOR:	EVELINA PAPAZYAN		FACILITY TYPE:	740
ADDRESS:	6951 LENNOX AVENUE		TELEPHONE:	(818) 780-5005
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 195		CENSUS: 78	DATE:	12/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:10 AM
MET WITH:	Aaron Feingold, Designated Responsible Staff		TIME VISIT/ INSPECTION COMPLETED:	06:10 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 Analysts (LPAs) Christine Yee and Erica Mosley conducted a joint unannounced required Annual Inspection using the CARE Inspection Tool and met with Aaron Feingold, Designated Responsible Staff. Also participating in today's visit was Evelina Papazyn, Consultant. The reason for today's visit was explained. The facility is a 3 storey residential building consisting of 30 bedrooms, a commercial kitchen, dining room, television room, lounge and a staff break room on the first floor. The second floor has 35 bedrooms, dining room, library and television room. 16 bedrooms out of the 35 bedrooms are designated for the dementia unit. The third floor has 36 bedrooms. The facility is fire cleared for 63 Ambulatory, 112 Non-ambulatory and 20 bedridden residents. Delayed egress is approved for the dementia unit. On today's visit, all 12 domains of the CARE Inspection Tool was reviewed, 8 staff and 8 resident files were reviewed and a tour of the physical plant, inside and outside were toured. Medications were also reviewed beginning at 3:00pm.The following rooms were inspected on today's visit: Room #s 101, #108, #124, #206, #212, #221, #234, #301, #316 and #335. Per tour of the resident rooms inspected, the rooms contained the required furniture. The bathrooms all contained a toilet, shower, grab bars, shower chair and a slip resistant mat. The water temperature were tested in the bathrooms and the water temperature in some of the bathrooms met Title 22 requirements and some did not have any hot water as the plumbers were still working on the plumbing needed to correct the continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/29/2025

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facility's issues with correcting the uneven distribution of hot water throughout the facility that was previously cited on a complaint visit conducted on 11/25/25. Per the facility, the previous contracted plumbing company came to fix the water temperature problem to meet Title 22 requirements but the problem was not fixed. Another plumbing company had to be hired to address the problem with the water temperature and they were on site working on the problem on today's visit. Per the contractor, the plumbing should be addressed by 12/30/25.

Per tour of the inside common areas, the appropriate furnishing and equipment were in place for its designated use. Per tour of the kitchen, sufficient perishable foods for a minimum of 2 days and non-perishable foods for a minimum of 7 days were observed on site. The facility also has food supplies delivered 2 times a week on Monday and Thursday. The common areas were observed to be clean and well maintained. The facility has 3 fire extinguishers located on each of the 3 floors. They were last inspected on 2/12/25. The last fire inspection was conducted on 2/17/25 by the facility's fire vendor and the facility passed the fire inspection for all fire prevention equipment. The facility has current general liability insurance that meets Title 22 requirement.

Per tour of the outside areas, there were chairs and tables available for resident use on the ground level and second floor. The large dumpsters located in the back parking lot were observed tightly sealed and in good condition. The outside areas were observed to be clean.

No deficiencies were cited on today's visit.

Exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2025

LIC809 (FAS) - (06/04)

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