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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610679
Report Date: 11/04/2024
Date Signed: 11/04/2024 01:37:54 PM

Document Has Been Signed on 11/04/2024 01:37 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 JOY 1FACILITY NUMBER:
197610679
ADMINISTRATOR/
DIRECTOR:		GRIGORYAN, MARINEFACILITY TYPE:
740
ADDRESS:18818 VALERIO STREETTELEPHONE:
(818) 699-2019
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 0DATE:
11/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Marine Grigoryan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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This is subsequent visit for Pre-Licensing initiated on 10/10/2024. On 11/04/2024, at 11:55 AM, Licensing Program Analyst (LPA), Huma Rahimi conducted an announced subsequent Pre-Licensing visit to the above facility and met with Marine Grigoryan, Licensee/Administrator, and explained the reason for the visit. At the time of this visit LPA did not observe any residents present in the facility. Fire Clearance dated on 09/23/2024, and received for six (6) Non-ambulatory residents. Hospice wavier for six (6) residents. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

LPA did not observe any personal belongings throughout the facility. LPA was informed that the applicant and the personal belongings were moved out of the facility as of 10/18/2024.

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, and a sink. Stove was observed in a good working condition. At 12:08 PM, LPA observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a locked box and inaccessible to residents. LPA observed a Fire Extinguisher and was last purchased on 08/22/2024. It was observed hanging on the kitchen wall.

MEDICATION ROOM: The centrally stored medication will be kept in the in the locked cabinet by the dinning area. Residents and staff files will be kept in the same cabinet locked and inaccessible to residents.



BEDROOMS: There are six (6) bedrooms designated for resident’s use. All bedrooms are private. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. The facility will have an awake staff. Auditory alarms were tested and observed to be operational. Continue on LIC 809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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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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 1
FACILITY NUMBER: 197610679
VISIT DATE: 11/04/2024
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BATHROOMS: There are three (3) bathrooms at the facility. LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and had non-skid mat The water temperature was noted at 111.2°.

LAUNDRY ROOM: The laundry room is located in the hallway by bedroom # (6). All the cleaning supplies and laundry detergents will be kept locked in box by the main entrance of the facility. The washer/dryer appear to be in good working condition.

COMMON AREAS: The facility maintains a comfortable temperature at 71°F. The living room and dining area
appeared clean and were properly furnished and has a television. No obstructions and or tripping hazards throughout the facility. LPA observed a working telephone for the facility.

SURROUNDING GROUNDS: The facility has sufficient backyard space. LPA did observe appropriate outdoor furniture in the backyard of the facility that can accommodate six (6) residents, LPA observed a covered shaded area for residents. LPA observed inside and outside activities for residents in care. There is no swimming pool or any bodies of water at the facility. The exit was free of any obstruction or hazard.

Garage/Storage: LPA observed a locked garage which will be used as storage. The facility will also keep the gardening tools and other cleaning items locked in the garage.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 12:45 PM, they were tested and observed to be operational.

Component III was conducted with the Licensee/Administrator.



Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted and a copy of this report was provided to the Applicant/Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
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