197610152-5-5-2023-31-AS-NGID-CUWNNB-20230821103623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610152
Report Date: 05/05/2023
Date Signed: 05/05/2023 04:49:56 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
04/28/2023 and conducted by Evaluator Angela Panushkina

COMPLAINT CONTROL NUMBER: 31-AS-20230428164713

FACILITY NAME:	PALACE OF JOY		FACILITY NUMBER:	197610152
ADMINISTRATOR:	GRIGORYAN, MARINE		FACILITY TYPE:	740
ADDRESS:	6701 KURL WAY		TELEPHONE:	(747) 265-6536
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 6	DATE:	05/05/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Artur Yezagelyan, Staff		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not have the Ombudsman poster posted.
Facility staff did not have the facility license posted.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced complaint visit to this facility to investigate the above allegations. LPA met with Staff #1 who granted access to the facility. Administrator and Staff #2 arrived at 10:10am and LPA explained the purpose of the visit.

Allegation: Facility staff did not have the Ombudsman poster posted.

During the visit conducted by the credible witness on 04/10/23 the facility did not have an Ombudsman poster posted. To investigate this allegation, LPA conducted an interview with the Administrator at 11:20am. During the interview, Administrator confirmed that the facility had no Ombudsman poster available due to the poster being damaged and removed in the beginning of March 2023. Administrator also informed LPA that a new poster was requested and provided by the Ombudsman on 04/10/23. During today’s visit LPA observed the poster being posted by the facility entryway. Based on interview with the Administrator this allegation is Substantiated at this time. Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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 4

Control Number 31-AS-20230428164713

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: 05/05/2023

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
26
27
28
29
30
31
32

Allegation: Facility staff did not have the facility license posted.

It was alleged that the facility did not have facility license, issued by the Department of Social Services (DSS), posted. To investigate this allegation, LPA conducted an interview with the Administrator at 11:20am and was informed that the facility license along with other signs and forms were framed and posted on a board by the entrance. Interview with the Administrator revealed that in the beginning of March 2023 the board fell because the frames were heavy. During today's visit LPA observed the board was up and had signs posted. However, the facility license was still missing. Based on LPA's observation this allegation is Substantiated at this time.

The following deficiencies are Substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC9099-D).

Exit interview conducted, Appeal Rights discussed, and a copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 31-AS-20230428164713

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: 05/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/12/2023 Section Cited CCR 87468.2(a)(10)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities (a) residents in…shall have all of the following personal rights: ... The licensee shall post the telephone numbers and addresses for the local offices of the … Ombudsman This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Upon arrival LPA observed Ombudsman poster by the main entryway. Deficiency cleared during the visit.
	8 9 10 11 12 13 14	Based on observations, interviews the licensee did not comply with the section cited above by not having the Obudsman poster posted from middle of March 2023 until April 10th, 2023, which posed apontiential health, safety, or Personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 05/12/2023 Section Cited CCR 87113	1 2 3 4 5 6 7	Posting requirements: The license shall be posted in a prominent location in the licensed facility accessible to public view. This requirement was not met as evidenced by	1 2 3 4 5 6 7	Administrator agreed to post the facility license issued by the Department of Social Services by the entryway and proof of picture will be submitted to LPA by POC date.
	8 9 10 11 12 13 14	Based on observations made by LPA, during today's visit, the licensee did not comply with the section cited above. LPA did not observe license issued by the Department of Social Services being posted by the main entry door, which poses a potential health, safety risk to persons 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.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4