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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608404
Report Date: 07/15/2024
Date Signed: 07/15/2024 03:11:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
07/11/2024 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20240711120733
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: 5DATE:
07/15/2024
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:NATHANIEL HEMEDES- Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not refund authorized representative
Staff will not respond to authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit for the above allegations. LPA arrived at the facility and was granted access by staff. Administrator Nathaniel Hemedes was present at the facility and explained the reason for the visit. LPA requested copies of LIC 500 and Resident Roster. LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations.

Allegation: Staff did not refund authorized representative
It was alleged that R1's responsible party wrote a check for $2,500 on 10/23/23 . Facility staff had noticed that the numerical and the written number doesn't match. Facility staff had asked R1's responsible party to write a second check and they would destroy the first check. R1's responsible party wrote a second check on 10/24/23 for the amount $2,500.00. However, the facility had cashed both checks and had not refunded R1's responsible party. (Continue on 9099C)

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
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 4
Control Number 31-AS-20240711120733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VICTOR JEM HAPPY HOMES
FACILITY NUMBER: 197608404
VISIT DATE: 07/15/2024
NARRATIVE
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Interview with the Administrator confirmed the allegation. The administrator admitted that they cashed both checks and they were unable to refund R1's responsible party due to financial hardships. The administrator confirmed that they will communicate with R1's responsible party and will refund them with amount of $2,000.00. Based on information obtained the allegation deemed Substantiated at this time.


Allegation: Staff will not respond to authorized representative

It was alleged that staff hasn't returned calls from R1's responsible party. Interview with the Administrator confirmed the allegation. Administrator admitted that R1's responsible party had called the facility multiple times regarding the refund and they didn't respond. Administrator stated that he wasn't able to return the calls due to busy schedule. Based on information obtained the allegation deemed Substantiated at this time.
Exit interview conducted, citations issued, appeal rights are given and a copy of this report is delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20240711120733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2024
Section Cited
HSC
1569.652
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Termination of admission agreement upon death of resident; ...and refunds (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual …responsible for the fees within 15 days after the personal property is removed.
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Administrator will refund R1's responsible party with the amount of $2,000 via check. Administartor will sent a copy of the front and back of the check by the POC date
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This requirement is not met as evidenced by; Based on the interviews and record review. The Licensee has not issue a refund of the prorated portion of the rent paid in advance. This poses potential risk to the personal rights of the residents in care.
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Type B
07/29/2024
Section Cited
CCR
87507(g)(5)
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87507 Admission Agreements; (g) Admission agreements shall specify the following: (5) Refund conditions. (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death…This requirement is not met as evidenced by
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Administrator will provide a copy of revised admission agreement and submit to the Licensing Office for review and approval by the POC date.
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Based on interviews and record review the Licensee failed to assure that the admission agreement includes condition of refund upon death of the resident. R1’s admission agreement does not indicates the procedure of the refund of payments upon death of the resident. This poses potential risk to the personal rights of the 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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20240711120733
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2024
Section Cited
CCR
87468.1(A)(9)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately
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Administrator will provide a statement of understanding this section of the CCR by the POC date.
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This requirement is not met as evidenced by;. Based on interviews, the Administrator did not respond to authorized representative.
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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: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4