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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608404
Report Date: 08/23/2023
Date Signed: 08/23/2023 04:51:19 PM

Document Has Been Signed on 08/23/2023 04:51 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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: 4DATE:
08/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:53 PM
MET WITH:TIME COMPLETED:
04:40 PM
NARRATIVE
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This Case Management visit was conducted in conjunction with a complaint investigation to address the deficiencies unrelated to the complaint.
During a Complaint Investigation, it was discovered that the two staff; Staff #1 (S1) and staff #2 (S2) have no Criminal Background Clearance and/or association to the facility and/or transfer therefore they are not associated to the facility. S1 started working in the facility since 08/14/2023 and S2 is working at the facility as of today 08/23/2023.

LPA Alvizar discussed the issue with the Administrator, and he was informed that the citation and civil penalties will be issued for allowing uncleared individuals to be present at the facility.

The deficiency was issued and recorded on LIC809D.

Exit interview was conducted and a copy of report was provided.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2023
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 2
Document Has Been Signed on 08/23/2023 04:51 PM - It Cannot Be Edited


Created By: Antonia Alvizar On 08/23/2023 at 04:06 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICTOR JEM HAPPY HOMES
FACILITY NUMBER: 197608404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2023
Section Cited
CCR
87355(e)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by:
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The facility Administrator has agreed to get background clearance and request a transfer of criminal record clearance for staff #1 and #2. Within 24h Submit criminal record clearance and/or association form and clear copy of an ID to the Licensing Office.
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Based on interview and review of licensing report summary staff #1 and #2 are not associated to the facility. No documentation to associate staffs has not been submitted. This poses a potential risk to residents in care.
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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:Naira Margaryan
LICENSING EVALUATOR NAME:Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023


LIC809 (FAS) - (06/04)
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