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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608404
Report Date: 07/15/2024
Date Signed: 07/15/2024 03:12:47 PM

Document Has Been Signed on 07/15/2024 03:12 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VICTOR JEM HAPPY HOMESFACILITY NUMBER:
197608404
ADMINISTRATOR/
DIRECTOR:		NATHANIEL HEMEDESFACILITY TYPE:
740
ADDRESS:831 DELAWARE ROADTELEPHONE:
(818) 232-7561
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 5DATE:
07/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:37 PM
MET WITH:NATHANIEL HEMEDES- AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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In conjunction to the complaint number 31-AS-20240711120733 Licensing Program Analyst (LPA) Mariana Agban conducted a case management- Deficiencies visit.
During the complaint investigation, it was confirmed that Licensee failed to submit a death report for Resident 1(R1) to CCL. LPA conducted a file review and didn't observe death report on file. In addition, during records review, LPA observed that Staff#1 (S1) and Staff #2 (S2) are not cleared nor associated to work in the facility. Administrator was advised to remove S1 and S2 immediately from the facility until they are clear and associated to the facility.


Exit Interview Conducted. Citations and Civil Penalties issued and a copy of this report
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/15/2024 03:12 PM - It Cannot Be Edited


Created By: Mariana Agban On 07/15/2024 at 01:47 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: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2024
Section Cited
CCR
87355(e)(1)

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This requirement is not met as evidenced by: Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption. This requirement was not met by evidence of:
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Administrator shall ensure that all staff obtain a Criminal Record Background Clearance and are associated to the facility prior to employment. Uncleared persons cannot return to work until they are cleared and associated to the facility.
Submit copies of Livescan and transfer requests by POC due date (tomorrow).
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Based on records review Staff 1 and Staff 2 are not cleared.
Civil penalties are being assessed in the amount of $500.00 for each staff.
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Type A
07/16/2024
Section Cited
CCR87533(e)(2)

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 Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met by evidence of:
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Administrator will provide proof of association for S1 and S2 by the POC date
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Based on records review S1 and S2 are NOT associated to this facility.
Licensee shall ensure all staff are cleared and associated to the facility prior to beginning employment.
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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: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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/15/2024 03:12 PM - It Cannot Be Edited


Created By: Mariana Agban On 07/15/2024 at 02:50 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: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2024
Section Cited
CCR
80061(b)

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80061(b) Reporting Requirements. Upon the occurrence…a report shall be made to the licensing agency..., a written report ...within seven days following the occurrence of such event.
This requirement was not met as evidence by
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Administrator will submit death report for R1 by the POC date.
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Based on file document review, the Licensee did not comply with the section cited above. Lincesee didn't submit a death report for R1 since they passed away on or around October or November 2023. This poses a potential health and safety risk to clients 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: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


LIC809 (FAS) - (06/04)
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