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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608404
Report Date: 01/09/2024
Date Signed: 01/09/2024 06:47:22 PM

Document Has Been Signed on 01/09/2024 06:47 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.RO, 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: 2DATE:
01/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:50 PM
MET WITH:TIME COMPLETED:
06:50 PM
NARRATIVE
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This Case Management visit is conducted in conjunction with complaint investigation to address the deficiencies unrelated to the complaint has nothing to do with complaint visit.

During Complaint Investigation, LPA Alvizar-Ettima discovered the following Full-Time Staff (S1) and (S2) have been present without a Criminal Background Clearance or Transfer and Association to this facility. S1 job title is Caregiver, first day of work was 12/28/2023. S2 job title is Caregiver, first day of work was 12/20/2023. LPA request/received S1 Washington Driver License. LPA request/received S2 Passport.

LPA verified using Guardian Background System Check, staff S1 and S2 names did not appeared on facility roster.

Based on review of Licensing visit History, LPA noted that on 08/23/2023 Licensee was cited for allowing 2 uncleared individuals to be present and work at the facility.
This is a second deficiency within last 12 month period. Therefore additional civil penalties $100.00 per/day per individual, up to 30 days, will be assessed at the time of this visit.

A citation and civil penalty were issued and recorded on LIC809D Copy of this report was provide 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
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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Document Has Been Signed on 01/09/2024 06:47 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 01/09/2024 at 04:54 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: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2024
Section Cited
CCR
87355(f)(e)(1)

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Criminal Record Clearance(f)Violation of Section 87355(e)... an immediate asse- ssment of civil penalties of one hundred dollars($100) per violation per day... (1) Subsequent violations within a 12 month period will result in a civil penalty of $100 per violation per day for a maximum of 30 days.
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Administrator has agreed to email the completed criminal background clearance and associate staff S1 and S2 to facility by POC due date
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Based on interview and review of Guardian Background System Check facility staff S1 and S2 are not criminal background clearenced and association to this facility. No documentation has been submitted to Community Care Lisensing. 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-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


LIC809 (FAS) - (06/04)
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