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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610152
Report Date: 03/27/2025
Date Signed: 03/27/2025 01:53:12 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.RO, 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
03/18/2025 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20250318150547
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:
03/27/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Marine Grigoryan, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff does not ensure medications are properly stored.
Staff does not ensure food is properly stored.
Staff does not ensure expired/ or rotten food are disposed.
Staff does not ensure hazardous chemicals are properly stored
Staff does not ensure dangerous items are properly stored.
INVESTIGATION FINDINGS:
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At 9:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with staff Tynaibek Usupbaev and the staff contacted the Administrator via phone. LPA explained the reason for the visit.

During course of the investigation, interviews and record review were made. At 9:10 AM, LPA requested client and staff roster. At 9:15 AM, LPA requested copies of pertinent information which include, but not limited to Staff Training, Dementia Program, Medication Policy and etc., relevant to the investigation. At approximately 9:25 AM, LPA conducted a physical plant tour. Between 9:40 AM – 1:45 PM, LPA conducted an interview with the Administrator, a staff, and five (5) out of five (5) residents.

Continue on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
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 5
Control Number 31-AS-20250318150547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALACE OF JOY
FACILITY NUMBER: 197610152
VISIT DATE: 03/27/2025
NARRATIVE
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Staff does not ensure medications are properly stored.

It was alleged that the facility left the keys in the medicine cabinet and unlocked medication in the refrigerator. On 01/06/2025 a credible witness conducted a visit to this facility and observed that the keys are left in the medicine cabinet and are not locked/secured. LPA conducted an interview with the Administrator who denied the allegation. Furthermore, during today’s visit LPA observed that the staff medications are unlocked in one of the kitchen cabinets and were accessible to residents in care. Additionally, LPA also observed that the key for the medication cabinet is visible and accessible in one of the kitchen drawers to residents in care. Based on credible witness and LPA’s observation during today’s visit this allegation is Substantiated.

Staff does not ensure food is properly stored.

It was alleged that the facility staff left food unsealed and open. On 01/06/2025 a credible witness conducted a visit to this facility and observed that food containers were left open. Additionally, on 03/10/2025, a credible witness conducted another visit and observed ice cream tub without a proper lid and a peanut butter jar open. LPA conducted an interview with the Administrator who confirmed that a peanut butter jar was open and unscrewed. Furthermore, during today’s visit LPA observed an ice cream tub open without a proper lid in the freezer. Based on credible witness, LPA’s observations during today’s visit, and the Administrator confirmation this allegation is Substantiated.

Staff does not ensure expired/rotten food are disposed.

It was alleged that the facility has expired/rotten food. On 01/06/2025 a credible witness conducted a visit to this facility and observed moldy tomatoes in the fridge. LPA conducted an interview with the Administrator who denied the allegation. However, during today’s visit LPA conducted a physical plant tour and observed wrinkled/aged chili peppers and expired milk with expiration date of 03/20/2025 in the refrigerator. Based on credible witness and LPA’s observations this allegation is Substantiated.

Continue on LIC 9099C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20250318150547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALACE OF JOY
FACILITY NUMBER: 197610152
VISIT DATE: 03/27/2025
NARRATIVE
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Staff does not ensure hazardous chemicals are properly stored.

It was alleged that the facility left cleaning supplies in the cabinet under the sink unlocked and accessible to residents in care. On 01/06/2025, a credible witness conducted a visit to the facility and observed cleaning supplies unsecured and accessible. LPA conducted an interview with the Administrator who confirmed that the facility staff left laundry detergents unlocked and accessible to residents in care. Furthermore, during today’s visit, LPA conducted a physical plant tour of the facility and observed cleaning supplies unlocked and accessible under the bathroom sink to residents in care. Therefore, based on credible witness observation, Administrator interview, and LPA’s observation this allegation is Substantiated.

Staff does not ensure dangerous items are properly stored.

It was alleged that the facility staff left a knife on the kitchen counter and a lighter in an unsecured drawer. On 03/10/2025 a credible witness conducted a visit to this facility and observed unlocked knife and a lighter. LPA conducted an interview with the Administrator who denied the allegation. However, during today’s visit, LPA conducted a physical plant tour and observed a lighter in an unsecured kitchen drawer. Furthermore, LPA did not observe any knives or other sharp objects unlocked. Based on the credible witness and LPA’s observations this allegation is Substantiated.

Deficiencies issued. Appeal rights discussed and given.


Exit interview conducted. Copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20250318150547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PALACE OF JOY
FACILITY NUMBER: 197610152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2025
Section Cited
CCR
87309(a)
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87309 Storage Space and Access: (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects..... pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.
This requirement is not met as evidenced by:
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Administrator will properly train staff to keep cleaning agents and chemicals inaccessible to residents and proof of training will be sent to LPA by the POC due date.
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Based on the credible witness and LPA's observation, the licensee did not comply with the section cited above in by leaving a lighter, a knife, and cleaning solutions accessible to residents in care which poses/posed an immediate health, safety or personal rights risk to persons in care.
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Type A
03/28/2025
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical & Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe & locked place…
This requirement is not met as evidenced by:
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Administrator agreed to schedule vendorized training for all staff by 03/28/25 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion.
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Based on the credible witness and LPA's observation, the licensee did not comply with the section cited above in by leaving medications unlocked and accessible to residents in care which poses/posed an immediate health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20250318150547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PALACE OF JOY
FACILITY NUMBER: 197610152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2025
Section Cited
CCR
87555(b)(28)
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87555(b)(28) General Food Service Requirements All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
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The Administrator has agreed to remove and discard the rotten foods from the refrigerator.
This part of the plan of correction met.
Train all staff on food service and discarding rotten foods. Submit to CCL the staff sign in sheet and training material.
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Based credible witness and LPA's observations the Licensee did not comply by having old/rotten perishable foods and expired milk in the refrigerator which poses a potential health and safety risk to the residents in care.
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Type B
04/03/2025
Section Cited
CCR
87555(b)(15)
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General Food Service Requirements: The following food service requirements shall apply: 15) All persons engaged in food preparation and service shall observe personal hygiene and food services... ...which protect the food from contamination.
This requirement is not met as evidence by
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Administrator will have in service training for current and new staff regarding this section 87555. Copy of in service training will be submitted to LPA.
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Based on credible witness and LPA's observations the licensee did not comply with the section cited above by not properly securing the peanut butter jar and an ice cream tub which poses a potential health and safety risk to the persons 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5