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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610152
Report Date: 05/24/2023
Date Signed: 05/24/2023 02:00:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
05/19/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20230519112325
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: 6DATE:
05/24/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Marine Grigoryan - AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Staff do not keep the facility free from mold
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with Marine Grigoryan and explained the reason for the visit.

LPA conducted physical plant tour at 9:32 AM, requested copies of facility documents relevant to the investigation at 9:46 AM and interviewed staff and residents between 10:00 AM to 12:30 PM. LPA also conducted record review between 12:30 PM to 1:30 PM.

Regarding the allegation that the Staff do not keep the facility free from mold, it was alleged that the facility has molds. LPA's observation during physical plant tour at 9:32 AM revealed that the ceiling room #2 and kitchen's ceiling had leak and currently in disrepair. LPA also observed that there are black spots on the kitchen ceiling. Based on the information gathered during this visit, the allegation is deemed substantiated at this time. Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
05/19/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20230519112325

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: 6DATE:
05/24/2023
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Marine Grigoryan - AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not treat residents with dignity or respect

Staff do not keep the facility free from odor
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Gary Tan conducted an unannounced initial complaint visit at this facility to investigate the above allegations. LPA met with Marine Grigoryan and explained the reason for the visit.

LPA conducted physical plant tour at 9:32 AM, requested copies of facility documents relevant to the investigation at 9:46 AM and interviewed staff and residents between 10:00 AM to 12:30 PM. LPA also conducted record review between 12:30 PM to 1:30 PM. Regarding the allegation that the staff do not treat residents with dignity or respect, it was alleged that the staff are unfriently, LPA's interview with five (5) residents today between 10:00 AM to 12:30 PM revealed that five (5) out of five (5) residents stated that they are getting all the care they need and they are treated with dignity by everyone in the facility and all the staff are respectful. Further interview also revealed that no one among the five (5) residents interviewed did not witness any staff being disrespectful or mistreating any resident. One (1) was resident was asleep during the LPA's entire visit. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20230519112325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALACE OF JOY
FACILITY NUMBER: 197610152
VISIT DATE: 05/24/2023
NARRATIVE
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32
(continued from LIC 9099-A)

Regarding the allegation that the Staff do not keep the facility free from odor, it was alleged that the facility has foul smell, LPA's physical plant tour at today at 9:32 AM revealed that the facility is generally clean and not malodorous all over. LPA also toured each room at the facility and did not observe any foul smell on any of the rooms.

Based on the information gathered during this visit, these allegations are deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20230519112325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PALACE OF JOY
FACILITY NUMBER: 197610152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2023
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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The administrator agreed to have the ceiling repaired immediately and will submit proof of repair on or before the POC date.
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Based on LPA observation during physical plant tour, the licensee failed to ensure that the facility is in good repair which poses a potential health and safety risk to the residents in care.
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7
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7
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7
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7
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: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4