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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610679
Report Date: 12/01/2025
Date Signed: 12/01/2025 12:19:35 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/01/2025 12:19 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: 6DATE:
12/01/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Marine Grigoryan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:47 PM
NARRATIVE
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At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced Annual Continuation visit to this facility; to continue with the Annual/Required visit initiated on 11/26/2025. LPA met with Ainura Amanzholova, Caregiver, who granted access to the facility. The Administrator Marine Grigoryan was contacted via a telephone and LPA explained the reason for the visit. Administrator arrived shortly after.
During today's visit, LPA reviewed medication and medication records for proper documentation and no discrepancies were observed. Moreover, LPA issued deficiencies which were observed during the initial annual inspection visit for the following:
  • Failure to submit incident reports to Community Care Licensing Division (CCLD).
  • Six (6) out of six (6) residents' file documents (consent forms, ID and emergency information, Appraisal Needs and Services Plan, LIC 613C personal rights and etc,) were missing signatures and dates.
  • Lack of proper pre-assessment/pre-placement of R3 and was accepted to the facility with a prohibited health condition.
  • Lack of proper training (prohibited health condition) of the staff.
  • No TB test results for R6.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2025
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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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)
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Document Has Been Signed on 12/01/2025 12:19 PM - It Cannot Be Edited


Created By: Huma Rahimi On 12/01/2025 at 10:32 AM
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 1
FACILITY NUMBER: 197610679

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2025
Section Cited
CCR
87411(a)

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87411 (a) Personnel Requirements – General (a) Facility personnel shall at all times be ... competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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The Administrator has agreed to the following:
All staff take state approved training on the regulation Personnel Requirement. Submit training schedule with the vendors name, date of schedule. Submit a complete the body check forms for each resident for the next two week.
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Based on file review and interviews, the licensee did not comply with the section cited above by not providing proper training to staff and accepting a resident with a prohibited health condition which poses an immediate Health, Safety, or Personal Rights risk to residents in care.
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Type A
12/02/2025
Section Cited
CCR87457(a)

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87457(a) Pre-Admission Appraisal - General:(a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or...for facility admissions. This requirement is not met as evidenced by
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The Administrator shall take state approved training on Pre-admissions appraisal. Submit training schedule, vendors name and vendor number. Once completed submit training material and sign in sheet to CCL.
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Based on interviews and resident records review the facility administrator failed to conduct a proper preplacement with resident #2 who had unstageable wound prior to admission to make sure the resident needs were met. This is an immediate health and safety risk to resident 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/01/2025 12:19 PM - It Cannot Be Edited


Created By: Huma Rahimi On 12/01/2025 at 10:48 AM
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 1
FACILITY NUMBER: 197610679

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2025
Section Cited
CCR
87211(a)(1)A,B&D

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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:
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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. R2s incident reports shall be submitted to LPA by POC date.
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Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R3's hospitalization on 08/06 & 10/21/25 which poses a potential health and safety risk to persons in care.
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Type B
12/08/2025
Section Cited
CCR87458(a)(1)(A)

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Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment...(1) A physical examination ....an examination for all of the following:
(A)Communicable tuberculosis. This requirement is not met as evidenced by:
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The Administrator agreed to obtain R6's tuberculosis test results and submit a copy of the results to LPA by POC due date.
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Based on record review, the licensee did not comply with the section cited above by not having TB test results in R6's file upon admission which poses a potential health and safety 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/01/2025 12:19 PM - It Cannot Be Edited


Created By: Huma Rahimi On 12/01/2025 at 11:18 AM
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 1
FACILITY NUMBER: 197610679

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2025
Section Cited
CCR
87506(a)(b)

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87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility ....... (b) Each resident’s record shall contain at least the following information:
This requirement is not met as evidenced by:
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The Administrator agreed to review all resident records and ensure that the required licensing forms are complete with signatures and dates and are in each resident file. Review of residents' file was conducted and POC cleared during today's visit.
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Based on record review and interview the licensee did not comply with the section cited above by not ensuring to have six (6) residents required licensing forms signed and dated which poses a potential Health, Safety, or Personal Rights risk to residents 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.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2025


LIC809 (FAS) - (06/04)
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