Palace of Joy 1

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Huma Rahimi, met with the Administrator, 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-20251209105654, The deficiencies were not alleged but observed by LPA. During the visit, the LPA was informed that two residents (R1 and R2) passed away while residing at the facility. According to the Administrator, R1 passed away on 09/09/2025 and R2 passed away on 10/28/2025. LPA reviewed the Licensing Information System and did not observe any incident or death reports submitted for R1's and R2's death at the facility. The Administrator acknowledged that no death reports were submitted to the Community Care Licensing Division (CCLD) or to the Regional Office (RO). Based on Title 22 regulations, a written Unusual Incident/Injury Report (LIC 624) must be submitted to CCLD within seven (7) days of the occurrence. The LPA reminded the Administrator that all staff members are mandated reporters and are responsible for ensuring timely reporting of deaths and other reportable incidents. The LPA instructed the Administrator to submit death reports for the following dates: 09/09/2025 – Resident R1 10/28/2025 – Resident R2 A deficiency was issued and appeal rights were explained. An exit interview was conducted, and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 10, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B&D · Plan of correction due date: Dec 17, 2025

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: 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 deaths which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: 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 death reports shall be submitted to LPA by POC date.

Type of visit: Case Management - Annual Continuation

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.the state’s words, verbatim · CDSS document, Dec 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 2, 2025

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: 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.the state’s words, verbatim · CDSS document, Dec 1, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87457(a) · Plan of correction due date: Dec 2, 2025

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 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.the state’s words, verbatim · CDSS document, Dec 1, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B&D · Plan of correction due date: Dec 8, 2025

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: 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.the state’s words, verbatim · CDSS document, Dec 1, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(a)(1)(A) · Plan of correction due date: Dec 8, 2025

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: 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.the state’s words, verbatim · CDSS document, Dec 1, 2025

Plan of correction: The Administrator agreed to obtain R6's tuberculosis test results and submit a copy of the results to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a)(b) · Plan of correction due date: Dec 8, 2025

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: 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.the state’s words, verbatim · CDSS document, Dec 1, 2025

Plan of correction: 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.

Type of visit: Required - 1 Year

At 9:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. 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. The Administrator arrived at the facility at 10:00 AM. Administrator designated the caregiver to conduct the physical plant tour of the facility with LPA. LPA was informed that the facility currently has six (6) residents, of which three (3) residents are non-ambulatory. Three (3) residents are currently on hospice. Facility has waiver for six (6) hospice residents. 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 9:10 AM, 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 11/18/2025. It was observed hanging on the kitchen wall. MEDICATION ROOM: The centrally stored medication are 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 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 113.4°. 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 in the facility storage area in the backyard. The washer/dryer were observed in working condition. COMMON AREAS: The facility maintains a comfortable temperature at 74°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. LPA observed a garage/storage area with PPE supplies and was observed locked an inaccessible to residents in care. The exit was free of any obstruction or hazard. SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 9:35 AM, they were tested and observed to be operational. Between 10:45 AM to 12:45 PM, LPA reviewed records of six (6) residents and two (2) staff records. LPA observed that all 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. On 08/06/2025, R3 was taken to the hospital Emergency Room (ER) for Fecal Impaction in Rectum, and on 10/21/25, R3 was taken to the hospital ER again for abdominal pain; however, no incident reports were submitted to Community Care Licensing (CCL) in a timely manner. Additionally, Administrator failed to provide a proper pre-assessment and accepted R3 with prohibited health condition and after accepting R3 no proper training were conducted with staff members. LPA also observed R6's file was missing TB test results. Due to the time constrains LPA will conduct a continuation of the annual inspection on another date to issue deficiencies and review medication. Exit interview conducted and copy of this report signed and provided.the state’s words, verbatim · CDSS document, Nov 26, 2025

Type of visit: Case Management - Other

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 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.the state’s words, verbatim · CDSS document, Nov 4, 2024

Type of visit: Prelicensing

At 09:30 am, Licensing Program Analyst (LPA), Huma Rahimi conducted an announced 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. At 9:45 AM LPA conducted a physical plant tour and observed that Licensee family still resides in the address. LPA observed that the facility closets are filled with personal items. All bedrooms were observed to have hospital beds with bed rails. LPA advised licensee that this is not allowed since they can get a resident anytime when LPA approve of licensing. LPA and licensee agreed to conduct a subsequent pre-licensing visit another time. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 10, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: GRIGORYAN, MARINE - Licensee/Administrator Interview Method: Telephone interview On 09/24/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Sep 24, 2024