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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603560
Report Date: 06/04/2026
Date Signed: 06/04/2026 06:10:23 PM

Document Has Been Signed on 06/04/2026 06:10 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 PLAZAFACILITY NUMBER:
197603560
ADMINISTRATOR/
DIRECTOR:		EVELINA PAPAZYANFACILITY TYPE:
740
ADDRESS:6951 LENNOX AVENUETELEPHONE:
(818) 780-5005
CITY:VAN NUYSSTATE: CAZIP CODE:
91405
CAPACITY: 195CENSUS: 89DATE:
06/04/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Marilou Mendoza, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Yee conducted an unannounced case management visit to issue a deficiency found while investigating complaint # 29-AS-20251124083503. LPA Yee met with Marilou Mendoza, Administrator and explained the reason for the visit.

On 11/24/2025, Community Care Licensing (CCL) received a complaint alleging a resident passed away due to the facility not seeking timely medical attention. The Department conducted an investigation. On 11/25/2025, from 9:09am to 5:00pm, Licensing Program Analysts (LPAs) Yee and Chochian conducted an unannounced complaint visit. During this visit, LPAs toured the facility, collected relevant documents including Special Incident Reports with fax confirmations, and documents for Resident 1 (R1) and Resident 2 (R2). On 12/24/2025, at approximately 5:28 pm the Department conducted interviews with former Administrator Aaron Feingold; on 3/10/2026 at 2:24pm conducted interviews with Family 1 (F1); and on 3/13/2026, at 9:46 am conducted interview with former administrator Denise Gilroy. The Department attempted multiple times to interview former Staff 1 (S1), who was the staff directly involved when R1 went to the hospital. However, S1 did not show up to the interview location and did not answer additional attempts to contact them for interview.

R1’s facility file was reviewed, including home health records and Incident reports. Records provided that R1 had diagnoses of Anemia, End Stage Renal Disease, Type 2 Diabetes, and was on Dialysis. R1 did not have

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2026
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: 06/04/2026
NARRATIVE
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any cognitive conditions and is able to communicate. Per R1’s medical assessment and care plan, R1 requires assistance with dressing, grooming, showering, incontinence care, and medication management.

During the investigation, medical records from Valley Presbyterian Hospital and home health records from Savanna Home Care, Inc. were collected and reviewed. R1’s home health records confirmed that the resident was receiving skilled nursing visits every day, prior to being transferred to the hospital. The home health records also confirm that the resident developed a Stage 1 pressure injury on 10/10/2025, and R1 received a referral for wound care the same day. On 10/13/2025, the home health records updated that the wound had progressed to a Stage 2 pressure injury.

On 10/14/2025, R1 was transported to the hospital and arrived around 11:13am. Per the Incident Report, R1 complained of right leg pain and the Administrator called 9-1-1. Records indicate the “Dispatch Complaint” for R1 was a “Diabetic problem” and the chief complaint was altered mental status. Hospital records indicate R1’s sacrococcyx wound was “unstageable” on 10/14/2025 at 11:30pm. R1 was admitted to the hospital due to the altered mental status, bradycardia, and hyperkalemia. Medical records indicate R1 had a history of end-stage-renal disease, was blind, and previously had a stroke.

Hospital records state R1 was admitted to the intensive care unit for “ongoing management of sepsis.” R1 had a previous diagnosis that included “bloodstream infection due to central venous catheter,” “sepsis due to methicillin resistant Staphylococcus Aureus,” and “other toxic encephalopathy.” Records state “In 2023 the patient sustained a distal femur fracture treated with a retrograde intramedullary nail (since removed), followed by a subsequent left hip fracture stabilized with an antegrade trochanteric entry nail.” A surgical procedure was scheduled on 10/27/25 to “remove the infected hardware”, but R1 passed away on 10/27/25 at the hospital.

During the interview with F1, they stated “[R1] didn’t want to go” to the hospital, “[R1] was still conscious,” and the facility staff had to make a “second request” to have R1 transported to the hospital. F1 stated “they
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC809 (FAS) - (06/04)
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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: 06/04/2026
NARRATIVE
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called me twice” to advise F1 that they were attempting to send R1 to the hospital. F1 did not believe the facility was neglectful in R1’s care, and indicated they felt the facility did a good job at monitoring R1’s change in conditions. F1 confirmed R1 was not in good health.

During an interview with former Administrator Denise Gilroy, administrator stated they were present during the incident where R1 was sent to the hospital, and stated that Staff #1 (S1) caused a delay in R1 being sent to the hospital because S1 had failed to call 9-1-1, and instead called a private ambulance. Information received from the reporting party confirmed there was a delay in calling 9-1-1 despite R1 being unresponsive and having low blood pressure. Former Administrator Feingold also confirmed S1 called for non-emergent transportation or R1 instead of following protocol. S1 was not technically terminated by the facility, but employment ended due to “Job Abandonment” after they did not show up for work for three (3) consecutive days.

Based on the interviews, admissions, and records reviewed, the facility did not provide R1 timely medical attention after they rapidly declined, and staff did not follow the protocol to immediately call 9-1-1


Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.


Exit interview was conducted, Appeals Rights discussed and a copy was provided..
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Christine Yee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2026 06:10 PM - It Cannot Be Edited


Created By: Christine Yee On 06/04/2026 at 02:31 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: 06/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2026
Section Cited
CCR
87465(g)

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Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…This requirement was not met as evidenced by:
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The Licensee will review their 911 protocol and provide current staff training to ensure that all staff know exactly when 911 is to be immediately contacted during an apparent medical crisis instead of endangering the health of the resident by unnecessay delays. Licensee will provide a written statement
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Based on interview and record review, the licensee did not comply with the section cited when R1 was not given timely medical attention on 10/14/25. 911 was not immediately called which posed an immediate health and safety risk to residents in care.
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 that they have reviewed their emergency protocol by 6/5/26 and have provided immediate staff training about the emergency protocol. Licensee will submit evidence of the completion of staff training about calling 911 when there is a life threatening medical crisis by no later then 6/11/26.

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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.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Christine Yee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2026


LIC809 (FAS) - (06/04)
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