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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610152
Report Date: 09/02/2026
Date Signed: 09/02/2026 12:21:49 PM

Document Has Been Signed on 09/02/2026 12:21 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: 5DATE:
09/02/2026
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Marine Grigoryan, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:40 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
At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted a case management visit to verify proper medication administration and management for residents in care. LPA met with the staff and the Administrator was contacted via telephone. LPA explained the reason for the visit. The Administrator left the facility and assigned the Licensee to sign and receive today's report.
During the visit, LPA reviewed R1’s Centrally Stored Medication Record (CSMR), medication packaging, and medication counts.
On 09/02/2026, LPA identified the following discrepancies:
  • Amlodipine: One tablet discrepancy; 45 tablets were present instead of the expected 46.
  • Divalproex Sodium: One day’s dose remained in the bubble pack, indicating one missed dose.
  • Escitalopram: Two tablets were missing from the new bubble pack.
  • Vitamin B1: New bubble pack was started on 08/31/2026 instead of 08/30/2026, indicating a missed/delayed dose.
  • Celecoxib: Medication supply was exhausted on 08/28/2026. R1 had not received the medication since the evening of 08/28/2026, and no refill was available from the pharmacy.
  • Trazodone: One extra tablet remained in the bottle, and the new bubble pack had not been started as scheduled.
No discrepancies were identified for Tamsulosin, Docusate Sodium, or Atorvastatin.
LPA determined that the facility failed to timely notify R1’s physician and Community Care Licensing Division (CCLD) regarding the medication discrepancies and Celecoxib interruption.
LPA discussed the findings with the Administrator and advised that medications must be administered as prescribed, discrepancies and medication interruptions must be immediately addressed and documented, and required notifications must be made timely.
Nichelle Gillyard
Huma Rahimi
DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2026
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 3
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 3
Document Has Been Signed on 09/02/2026 12:21 PM - It Cannot Be Edited


Created By: Huma Rahimi On 09/02/2026 at 11:50 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
FACILITY NUMBER: 197610152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2026
Section Cited
CCR
87465(c)(2)

1
2
3
4
5
6
7
87465- Incidental Medical and Dental Care:
c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee agreed to schedule vendorized training for all staff by 9/3/26 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above by failing to ensure that R1’s prescribed medications were administered as ordered, medication discrepancies were timely addressed, and R1’s physician and CCLD were timely notified of medication errors and the interruption of prescribed medication. This poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
09/09/2026
Section Cited
CCR87211(a)(1)A,B&D

1
2
3
4
5
6
7
(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
The Licensee agreed to notify R1’s physician and submit an incident report to CCLD regarding R1’s medication discrepancies identified during LPA’s review on 09/02/2026. The discrepancies involved medications prescribed from 06/01/2026 through 08/29/2026,
8
9
10
11
12
13
14
Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD and R1's Physician regarding R1's medication discrepancies, which poses a potential health and safety risk to persons in care.
8
9
10
11
12
13
14
during which period the medications were expected to be administered as prescribed.
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: 09/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2026


LIC809 (FAS) - (06/04)
Page: 3 of 3