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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608404
Report Date: 01/09/2024
Date Signed: 01/09/2024 06:42:24 PM

Substantiated


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
01/02/2024 and conducted by Evaluator Antonia Alvizar-Ettima
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240102152100
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: 2DATE:
01/09/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Staff:Nerissa Quiba Destefano &Rita Engalla Flores TIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff are not properly storing residents medication

INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Antonia Alvizar-Ettima conducted unannounced complaint visit to the facility. LPA met with staff (S#1 and S#2) and granted entry. At 12:20p.m. Administrator arrived, and LPA explained the purpose of this visit.

At 11:50p.m., LPA Alvizar-Ettima and S#2 conducted a physical plant inspection. At approximately 11:55 a.m., LPA Alvizar interviewed two (2) staff, two (2) out of two (2) residents. At 12:20p.m. LPA requested copies of staff, residents’ roster and other pertinent documents relevant to the investigation.

Staff are not properly storing residents’ medication.

It is alleged that medication is being found sitting out in the kitchen area. During inspection LPA did not observe any medication in the kitchen area or elsewhere in the facility. However, during inspection, LPA discovered that medication cabinet lock is broken, and medications are accessible to the residents.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
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 5
Control Number 31-AS-20240102152100
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: VICTOR JEM HAPPY HOMES
FACILITY NUMBER: 197608404
VISIT DATE: 01/09/2024
NARRATIVE
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Continuation from LIC 9099

During interview, Administrator admitted that medication cabinet lock has been broken for a couple days. Based on inspection and interviews there is sufficient information to support the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Citation was issued and recorded on LIC9099D.


Exit interview was conducted, appeal rights were discussed, and a copy of report was provided to Nathaniel Hemedes.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/02/2024 and conducted by Evaluator Antonia Alvizar-Ettima
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240102152100

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: 2DATE:
01/09/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Staff: Nerissa Quiba Destefano&Rita Engalla FloreTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff are not providing residents with reasonable accomodations


INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Antonia Alvizar-Ettima conducted unannounced complaint visit to the facility. LPA met with staff (S#1 and S#2) and granted entry. At 12:20p.m. Administrator arrived, and LPA explained the purpose of this visit.

At 11:50AM LPA Alvizar-Ettima and S#2 conducted a physical plant inspection. At approximately 11:55AM LPA interviewed two (2) staff, two (2) out of two (2) residents. At 12:20PM LPA requested copies of staff, residents’ roster and other pertinent documents relevant to the investigation.

It is alleged that facility do not have a call light. Resident interviews during this visit reveal that they don’t use a call light. They call staffs name, and they came to assist. Residents disclosed that staff provides reasonable accommodations if needed. Staff #2 (S2) and Administrator interviews reveal that residents call the staff by names and staff goes to the residents’ room to assist.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20240102152100
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: VICTOR JEM HAPPY HOMES
FACILITY NUMBER: 197608404
VISIT DATE: 01/09/2024
NARRATIVE
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Continuation from LIC 9099 -A

At about 11:53 AM LPA Alvizar- Ettima observed a resident calling staff’s name and staff went to the resident’s room for assistance.

Based on interviews, and observation, there is an insufficient information to support the allegation. Therefore, the allegation are UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of report was provided to Administrator Nathaniel Hemedes
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20240102152100
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: VICTOR JEM HAPPY HOMES
FACILITY NUMBER: 197608404
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/10/2024
Section Cited
CCR
87465(h)(C)(2)
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Incidental Medical and Dental Care(h)The following requirements shall apply to medications which are centrally stored(C) Because...dangers related to the medication itself(2)...medicines shall be kept in a safe and locked place that is not accessible to persons other than employees…
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Administrator has agreed to replace the lock on the medication cabinet and email pictures of new lock and proof of purchase receipt by POC due date.
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Based on inspection LPA discovered that medication cabinet lock is broken, and medications are accessible to the residents.
This poses a potential risk to resident 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.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5