<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610152
Report Date: 05/20/2025
Date Signed: 05/20/2025 04:31:00 PM

Document Has Been Signed on 05/20/2025 04:31 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PALACE OF JOYFACILITY NUMBER:
197610152
ADMINISTRATOR/
DIRECTOR:		GRIGORYAN, MARINEFACILITY TYPE:
740
ADDRESS:6701 KURL WAYTELEPHONE:
(747) 265-6536
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 6DATE:
05/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Marine Grigoryan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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
Licensing Program Analyst (LPA) Huma Rahimi, met with the staff Keneshbek Minzhasharov, and the Administrator Marine Grigoryan was contacted via phone and LPA explained the reason for the case management visit. The purpose of the case management visit is to address deficiencies observed during the course of complaint # 31-AS-20250516105015, The deficiencies were not alleged but observed by LPA.

During the visit, LPA was informed that R1 is having behavior issues/incidents on daily basis. Furthermore, on 05/02/2025, R1 had a bowel movement incident. On 03/27/25, R2 was taken to the hospital by calling 9-1-1 for shortness of breath. However, no incident reports were submitted to the Community Care Licensing Department (CCLD) in a timely manner for R1 and R2. LPA reviewed all incident reports on a system and did not observe any Incident Reports regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident/Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting.

LPA informed the Administrator to submit an incident report that occurred on:


  • 05/02/25 for R1
  • All other incidents (related to R1)
  • 03/27/25 (R2) hospitalization
Moreover, upon arrival to the facility LPA conducted interviews and concluded that two (2) out of two (2) staff were not able to communicate in English with the residents of which the majority speak English. Furthermore, interviews with five (5) out of six (6) residents who were able to communicate confirmed that
Continue on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/20/2025
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
they have trouble communicating with staff for their basic needs. Lastly, during today's visit both staff used translator application on their phone to communicate/interview with LPA. Therefore, a deficiency will be issued.
Lastly, during the course of investigation LPA observed a small scratch on R2's nose. During the interview LPA was informed that R2 was physically abused by Staff #1 (S1). LPA observed that R2 was not consistent with the information provided to LPA. LPA conducted a file review of R2 and observed that R2 is diagnosed with dementia, schizophrenia, and bipolar disorder. Additionally, LPA conducted interviews with the Administrator, and two staff. All parties interviewed denied ever witnessing or physically abusing anyone in the facility. Therefore, due to the lack of evidence LPA was unable to conclude that R2 was ever physical abused by facility staff.

Deficiencies cited during today's visit and appeal rights explained and given.
Exit interview conducted and copy of this report signed and delivered.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/20/2025 04:31 PM - It Cannot Be Edited


Created By: Huma Rahimi On 05/20/2025 at 03:39 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: 05/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2025
Section Cited
CCR
87411(d)(3)

1
2
3
4
5
6
7
87411-Personnel Requirements General-(d)(3)Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.,.This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator/Licensee agrees to put in writing their plan for hiring or ensuring English Speaking staff are always on shift and submit the plan by the POC date. Additionally, Administrator shall submit an updated LIC500 to reflect all staff.
8
9
10
11
12
13
14
Based on LPA’s interview and observation, the administrator does not have staff available to communicate with residents to provide care which poses a potential risk to the residents in care.
8
9
10
11
12
13
14
Type B
05/27/2025
Section Cited
CCR87211(a)(1)A,B&D

1
2
3
4
5
6
7
87211(a)(1)A,B&D-Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's and R2's incident reports shall be submitted to LPA by POC date.
8
9
10
11
12
13
14
Based on interviews and record reviews, the licensee did not comply with the section cited above by not notifying CCLD regarding R1's and R2's incident reports which poses a potential health and 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4