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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610152
Report Date: 03/15/2023
Date Signed: 03/15/2023 09:17:57 PM

Document Has Been Signed on 03/15/2023 09:17 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., STE. 250
WOODLAND HILLS, CA 91364
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Artur YezagelyanTIME COMPLETED:
03:30 PM
NARRATIVE
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LPA Spaeth conducted an announced visit to conduct a investigation of Complaint #31-AS-20230308152917. During LPA's visit, LPA observed caregivers were not wearing a mask. Also, LPA observed two bottles of beer in the refrigerator. LPA explained to caregivers facility staff must wear masks and alcohol beverages cannot be available within the facility.

Upon LPA's arrival, LPA asked for caregivers names to determine if staff has been fingerprinted, cleared and associated to the facility. LPA requested the on duty LPA at the Woodland Hills Regional Office to check within Guardian for confirmation the caregivers have been fingerprinted and cleared. The On duty LPA stated one caregiver had been cleared but the other caregiver's application was incomplete. LPA reminded that anyone working directly with residents must receive clearance prior to their start date. Immediate civil penalty of one hundred dollars ($100) per day has been issued.

The following deficiencies are substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-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
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 03/15/2023 09:17 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 03/15/2023 at 11:25 AM
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., 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 A
03/15/2023
Section Cited
CCR
87470(a)(5)

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87470 infection Control Requirements. (a) A licensee shall ensure that infection control practices are maintained..: (5) All staff... .. shall practice and maintain respiratory etiquette….to minimize exposure to potential illness. ..
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During LPA's visit, LPA observed caregivers immediately placed mask while working in the facility. LPA advised staff that all staff are required to wear masks when in the facility.
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This requirement was not met as evidenced by: Upon entering the facility, LPA observed staff member was not wearing a mask which poses an immediate health and safety risk to residents in care.
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Type A
03/15/2023
Section Cited
CCR87705(f)(2)

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87705 Care of Persons with Dementia. The following items shall be made inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, ...and disinfectants. This requirement is not met as evidenced by:
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Caregivers removed the alcohol from the refrigerator and removed it from the facility which made it inaccessible
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Based on todays observation, two bottles of beer were found accessible in the facilitly refrigerator. This poses an immediate health 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: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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/15/2023 09:17 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 03/15/2023 at 02:49 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., 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 A
03/15/2023
Section Cited
CCR
87355(e)(1)

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87355 (e)(1) Criminal record Clearance All individuals subject to a criminal record review pursuant to Health & Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (1) obtain a California clearance or a criminal record excemption as required by the Dept.....
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This is a zero tolerance violation. Caregiver was sent home during the visit. LPA stated to Caregiver they cannot come back until they are cleared and associated. Immediate civil penalty of R1 100 X1 day has been issued for a total of $100.
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This requirement is not met as evidenced by: LPA observed a caregiver assisting R1 in the living room. Caregiver working at the facility prior to obtaining criminal record clearance 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: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


LIC809 (FAS) - (06/04)
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