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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608404
Report Date: 02/22/2022
Date Signed: 02/22/2022 05:03:19 PM

Document Has Been Signed on 02/22/2022 05:03 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VICTOR JEM HAPPY HOMESFACILITY NUMBER:
197608404
ADMINISTRATOR:NATHANIEL HEMEDESFACILITY TYPE:
740
ADDRESS:831 DELAWARE ROADTELEPHONE:
(818) 232-7561
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 3DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Nathaniel HemedesTIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator Nathaniel Hemedes and explained the reason for the visit. Physical Plant was toured, clients files and medication records were reviewed, staffs files records reviewed and food supply was inspected. The facility is licensed for six (6) residents over the age of 60, with a hospice waiver for two (2) residents, and currently has one (1) resident on hospice.

The facility is a single story structure located in a residential neighborhood. It consists of the following: 3 resident bedrooms, 2 full bathrooms, living room, kitchen, dining area, laundry room, backyard with shaded patio area, and a detached garage. The garage used as office. Facility sketch did not include a garage. . Front yard is landscaped with grass. The home has a backyard area with shaded patio furniture.

LPA and Administrator toured the facility. LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways were free of obstruction. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit.

The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods. Sharps, cleaning supplies are locked and inaccessible to residents. Battery operated smoke detectors and carbon monoxide detector were in compliance and operational. The facility is equipped with a fire pull alarm. Fire extinguishers are fully charged.


The common areas (dining room, living room) appeared to be clean and were properly furnished. Resident rooms were sanitary and had the required furniture and furnishings.

Continue LIC809C





SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VICTOR JEM HAPPY HOMES
FACILITY NUMBER: 197608404
VISIT DATE: 02/22/2022
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The bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested and maintained within the required range of 105-120*F. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations.

LPA reviewed 3 resident files to confirm emergency contact is updated. Residents medications reviewed. Medications documented properly and stored appropriately.


LPA also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared. Administrator file was not observed.
The backyard had discarded furniture ( shovels, gardening tools, pieces of wood, chairs) and other hazards.

Based on this inspection, deficiencies were observed at this time in the areas evaluated. See LIC 809D for deficiencies.

Exit interview conducted with Administrator and a copy of the report with Appeal Rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/22/2022 05:03 PM - It Cannot Be Edited


Created By: Nune Margaryan On 02/22/2022 at 04:09 PM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VICTOR JEM HAPPY HOMES
FACILITY NUMBER: 197608404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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. LPA observed the backyard had discarded furniture (shovels, gardening tools, pieces of wood, chairs) and other hazards.
POC Due Date: 02/22/2022
Plan of Correction
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Cleared during the visit. No further action needed.
Type B
Section Cited
CCR
87412(a)
Personnel Records. The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above
which poses/posed a potential health, safety or personal rights risk to persons in care.
LPA did not observe a file for Administrator.
POC Due Date: 03/08/2022
Plan of Correction
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Administrator shall maintain a complete Administrator file on the premises and submit proof by POC due date.

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:Wei Siew Ho
LICENSING EVALUATOR NAME:Nune Margaryan
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2022


LIC809 (FAS) - (06/04)
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