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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610679
Report Date: 09/29/2026
Date Signed: 09/29/2026 12:52:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/09/2025 and conducted by Evaluator Huma Rahimi
COMPLAINT CONTROL NUMBER: 31-AS-20251209105654
FACILITY NAME:PALACE OF JOY 1FACILITY NUMBER:
197610679
ADMINISTRATOR:GRIGORYAN, MARINEFACILITY TYPE:
740
ADDRESS:18818 VALERIO STREETTELEPHONE:
(818) 699-2019
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:6CENSUS: 4DATE:
09/29/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Marine Grigoryan, AdministratorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Resident died due to staff neglect.
Staff did not provide resident with medical assistance.
INVESTIGATION FINDINGS:
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At 9:50 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted a subsequent complaint visit to investigate the above stated allegations. LPA met with the staff and the Administrator was contacted. LPA explained the reason for the visit. The Administrator arrived shortly after.

An initial complaint visit was conducted on 12/10/2025. During that visit, LPA LPA requested resident and staff roster. LPA conducted a physical plant tour. LPA obtained copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan, relevant to the investigation. During today’s visit, between 10:30 am to 11:45 am, LPA conducted interviews with the Administrator, and Staff #1 (S1).

Continue on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20251209105654
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/29/2026
NARRATIVE
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Allegation 1: Resident died due to staff neglect.

It is alleged that facility staff neglected Resident #1 (R1), resulting in R1's death. To investigate the allegation, LPA interviewed the Administrator and S1. LPA also reviewed the facility records, incident report, physician report, Hospice care plan, 9-1-1/ Emergency Medical Services (EMS) records, and death certificate.

R1 was admitted to the facility on 08/07/2025. LPA reviewed the physician report, which documented that R1 was able to communicate and follow instructions.

On 08/27/2025, R1 was found on the floor next to the bed after attempting to get up. R1 initially reported no pain or discomfort, and no visible injuries were observed. Staff assisted R1 back to bed and later contacted 9-1-1 as a precaution. EMS responded and assessed R1. EMS documented left lower-extremity pain and no swelling, shortening, or rotation. R1 declined transportation to the hospital for further medical evaluation.

LPA reviewed the Hospice care plan, which confirmed R1 was receiving Hospice services. R1 passed away on 09/11/2025, and the death certificate documented cardiac arrest as the cause of death.

Based on the information reviewed, there was insufficient evidence to establish that staff neglect caused or contributed to R1's death. Therefore, this allegation is deemed Unsubstantiated at this time.

Allegation 2: Staff did not provide resident with medical attention.

It is alleged that facility staff failed to provide R1 with medical attention following a fall and provided only pain medication. To investigate the allegation, LPA interviewed the Administrator and S1. LPA also reviewed the incident report, facility records, Hospice care plan, and 9-1-1/ Emergency Medical Services (EMS) records.

On 08/27/2025, staff found R1 on the floor next to the bed. Staff conducted an initial assessment, and R1 reported no pain or discomfort at that time. No visible injuries were observed, and staff assisted R1 back to bed.

Continue on LIC 9099C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20251209105654
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/29/2026
NARRATIVE
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Later that morning, the staff contacted 9-1-1. EMS responded and conducted an assessment. EMS documented that R1 reported left lower-extremity pain following the fall. EMS offered transportation to the hospital for further evaluation and R1 declined transport. The records reviewed did not establish that staff failed to seek medical attention or that documented.

LPA reviewed the 9-1-1/EMS records, which corroborated that emergency medical services were contacted and that R1 was assessed by EMS. The records reviewed did not establish that staff failed to seek medical attention or that staff provided only pain medication instead of obtaining medical evaluation. Therefore, the allegation is Unsubstantiated at this time.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3