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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610152
Report Date: 09/29/2022
Date Signed: 09/29/2022 12:13:38 PM


Document Has Been Signed on 09/29/2022 12:13 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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: 5DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Artur YezagelyanTIME COMPLETED:
12:25 PM
NARRATIVE
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At 10:20 a.m. on 09/29/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out.

The facility was last visited on 10/19/2021 for a case management visit. It is a single story building with 4 bedrooms, 3 bathrooms, kitchen, pool, common areas, and outdoor areas. It has an approved fire clearance for 6 residents, of which 4 may be non-ambulatory and 1 may be bedridden in Bedroom #4. The facility serves residents with dementia. Approved hospice waivers for 4.

LPA observed a sign posted at the front for “No Smoking – Oxygen in Use”. LPA was screened for infectious disease upon entry. LPA signed in on the visitor log, Staff added columns on the visitor log to track temperature, symptoms, and vaccination status during the visit. Postings at the main entrance included confidential complaint contacts, emergency contacts, personal rights, facility license, non-discrimination policy, and COVID precautions.

The facility had 4 bedrooms. 1 is private and 3 are shared. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. Beds in shared rooms were at least 6 feet apart for social distancing. LPA observed 7 beds in the facility, and staff confirmed that only 6 will be used. Staff confirmed their understanding of their capacity limitation. Bedroom #4 was cleared for a bedridden resident. Bedroom #4 was vacant. The fire door to Bedroom #4 is not properly suspended with a magnet. Instead, the fire door was shut. LPA explained to staff that the door must be suspended by a magnet and secured properly before a resident moved in to the room. At approximately 10:35 a.m. LPA observed an auditory alarm removed from the rear sliding door. Staff confirmed it was broken. Outside, LPA observed a pool gate without a lock, 6 paint cans near the pool, and a storage shed with cleaning solutions unlocked and accessible. Staff locked the pool gate, placed the paint cans in storage, and locked the storage shed. Ramps and handrails were in good condition. Fireplace was covered appropriately.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PALACE OF JOY
FACILITY NUMBER: 197610152
VISIT DATE: 09/29/2022
NARRATIVE
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The facility had 3 bathrooms. All bathrooms contained liquid soap, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. Staff stated that toilet paper and paper towels are provided with each use due to residents with impulse control issues. At 10:40 a.m. LPA measured the water temperature in the private bathroom of Bedroom #4 to be 120 degrees Fahrenheit. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 10:50 a.m. LPA measured the room temperature to be 76 degrees Fahrenheit.

LPA observed an adequate supply of perishable and non-perishable food in the kitchen. At 10:52 a.m. LPA measured the refrigerator and freezer temperatures to be 40 and 0 degrees Fahrenheit, respectively. Kitchen appliances were sanitary and functional. Sharps were locked below the counter top. A washer and dryer in good condition were located near the kitchen. At approximately 10:54 a.m. a cleaning solution was found in the bathroom adjacent to the kitchen. Staff immediately locked the cleaning solution in the storage shed.

All emergency exit paths were free from obstructions. Exit gates were unlocked with inward facing latches. Emergency Disaster Plan posted at the front. At 11:16 a.m. staff tested the dual-purpose carbon monoxide and smoke detectors in Bedroom #4 to be operable. Detectors were hardwired and functioned simultaneously. An additional verbal alert sounded when detector was tested. At 10:30 a.m. LPA observed a fully charged fire extinguisher near the kitchen, It was purchased on 09/30/2021 and had a receipt attached.

During today's inspection, the facility was not in compliance with Title 22 regulations. Citations issued on LIC 809-D page. Exit interview conducted. Copy of report, appeal rights, and citations issued.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/29/2022 12:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: PALACE OF JOY
FACILITY NUMBER: 197610152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 6 cleaning solutions which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee stored, locked, and made all hazardous materials inaccessible during visit. Licensee attached a new lock to the storage shed. POC cleared.
Type A
Section Cited
CCR
87307(e)
87307 Personal Accommodations and Services
(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water, when not in active use by residents, through fencing, covering or other means.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 pool gate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2022
Plan of Correction
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Licensee locked the pool gate during visit. A new lock was attached. POC cleared.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 09/29/2022 12:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: PALACE OF JOY
FACILITY NUMBER: 197610152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 3 auditory alarms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2022
Plan of Correction
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Licensee to reattach all auditory alarms and send proof of correction by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5