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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610152
Report Date: 03/15/2023
Date Signed: 03/15/2023 09:18:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/08/2023 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20230308152917
FACILITY NAME:PALACE OF JOYFACILITY NUMBER:
197610152
ADMINISTRATOR:GRIGORYAN, MARINEFACILITY TYPE:
740
ADDRESS:6701 KURL WAYTELEPHONE:
(747) 265-6536
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 5DATE:
03/15/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Artur YezagelyaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not issue resident a refund.
INVESTIGATION FINDINGS:
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On 3/15/2023 Licensing Program Analyst (LPA) Melissa Spaeth arrived at the facility to conduct a 10-day unannounced complaint visit and explained the purpose of the visit. Upon arrival, LPA was greeted by caregivers and LPA was allowed entrance to the facility. At approximately 10:45 a.m., licensee Artur Yezagelyan arrived to the facility.

Allegation: Staff did not issue resident a refund.

At 10:45 until 10:55 am. LPA conducted a physical plant tour. LPA interviewed Licensee from 11:00 am until 11:30 am and interviewed R1's family member from 11:30 am until 11:50 am LPA reviewed resident's files at 11:50 am until 12:15 pm. LPA interviewed the resident (R1) from 12:20 pm until 12:35 pm.

During LPA's interview of the Administrator, Marine Grigoryan, Administrator stated received a referral from an agency regarding resident (R1). R1 moved into the facility the evening of 10/25/2022 but on 10/26/2022
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20230308152917
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALACE OF JOY
FACILITY NUMBER: 197610152
VISIT DATE: 03/15/2023
NARRATIVE
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 R1 decided no longer wanted to live at the facility and left on 10/26/2022. Administrator stated a signed Admissions Agreement was not received prior to the arrival of the resident. R1 stated upon arrival to the facility, R1 gave a cashier's check to the caregiver. Administrator stated did not remember if caregiver had received the cashier's check but checked bank records which confirmed the check was received.

LPA interviewed R1's family member who stated a cashier's check was prepared by R1's bank and the family member gave R1 the check and R1 placed the check in R1's pocket. LPA Spaeth interviewed the resident (R1) on 3/15/2022 at 12:30 pm via phone call who stated gave a cashier’s check to the caregiver on the evening of 10/25/2022. LPA asked if R1 received a refund from the facility and R1 stated no.

Based upon LPA's interview of the Administrator, R1 and R1's family member, the allegation, staff did not issue resident a refund is substantiated.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 9099-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20230308152917
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALACE OF JOY
FACILITY NUMBER: 197610152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2023
Section Cited
CCR
87507(c)
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87507 Admissions Agreement (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative if any and the licensee…no later than seven days following admissions.
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 Administrator will send a refund check to the Resident and send a copy of the refund check to LPA Spaeth via email..
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This requirement was not met as evidenced by: Based on LPA's interviews of the resident, resident's famly member and Administrator, the Admissions Agreement was not signed by the resident and a payment of $2,500.00 was received by facility staff when R1 moved into the facility.
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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.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3