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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608404
Report Date: 01/29/2025
Date Signed: 01/30/2025 08:08:27 AM

Document Has Been Signed on 01/30/2025 08:08 AM - 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/
DIRECTOR:		NATHANIEL HEMEDESFACILITY TYPE:
740
ADDRESS:831 DELAWARE ROADTELEPHONE:
(818) 232-7561
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 6CENSUS: 5DATE:
01/29/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nathaniel Hemedes, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Nadia Shahbazian and Angela Panushkina, conducted a CASE MANAGEMENT visit at this facility to issue deficiency in conjunction with complaint control no: 31-AS-20250122142449. LPAs met with the Administrator and explained the reason for the visit.

LPA conducted a physical plant walk through, at approximately 10:15 AM, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. At 10:20 AM, LPAs conducted an interview with the Administrator, two (2) staff members and five (5) residents. LPAs also requested and reviewed five (5) resident files. Upon review of documents LPA observed the following:

  • Resident #2 (R2) is currently on hospice and R3 (non-hospice) had full bed rails. Review of records revealed that both residents had no Physician's order on file.
  • R1 and R5 had half (½) bed rails. Review of R1's and R5's facility records revealed that no Physician's order was available.
  • Moreover, LPAs observed five (5) out of five (5) residents facility files were incomplete, missing forms and and signatures.
  • During the interview with S1 and S2, LPAs were informed that they stay at the facility at night and S1 is sleeping in a stow away bed and had his/her personal items in the room #1 Continue on LIC809-C
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/29/2025
NARRATIVE
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  • In addition, during the interview with R2, LPAs were informed that S2 sleeps on the bed in room #3. Interview with S2 confirmed that during the night time, S2 is sleeping in R2's room. LPAs reviewed the facility license and observed that the facility is licensed for awake staff.


Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.


Exit interview conducted. Appeal rights explained. Copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/30/2025 08:08 AM - It Cannot Be Edited


Created By: Nadia Shahbazian On 01/29/2025 at 02:39 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2025
Section Cited
CCR
87608(a)(5)(B)

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Bed rails that extend the entire length of the bed are prohibited except for... hospice care and have a hospice care... This requirement is not met as evidenced by:
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Licensee/Administrator will request a current and updated hospice care plan for R2 and which indicates the need for the full rails.
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Based on LPAs observation and record review, the licensee did not comply with the section cited above by not requesting an exception for a non hospice resident R3 to have a full bed rail. Moreover, no written Doctors' order was observed on file for R2's full bed rail and R1's and R5's 1/2 bed rails, which poses an immediate health and safety risk to persons in care.
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Administrator will remove R3's full bed rail and request 1/2 bed rail for R1's, R3's and R5's physicians. Copy of the Hospice care plan fro R2 and physician orders will be submitted as POC.

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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:Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/30/2025 08:08 AM - It Cannot Be Edited


Created By: Nadia Shahbazian On 01/29/2025 at 02:42 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: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2025
Section Cited
CCR
87506(a)

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Resident Records. The licensee shall ensure that... current record is maintained... readily available.... This requirement is not met as evidenced by:
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Licensee/Administrator will complete files for all residents. Once completed licensee/administrator will submit a signed, dated self certification
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Based on record review the licensee did not comply with the section cited above by not maintaining complete facility files for 5 out of 5 residents which poses a potential health, safety or personal rights risk to persons in care.
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that all resident files have been, reviewed, updated and complete as required by the cited regulation.
Type B
02/05/2025
Section Cited
CCR87303(a)

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Personal Accommodations and Services: Living accommodations and grounds shall be related to the facility's function... This requirement is not met as evidenced by:
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Licensee/Administrator will notify the LPA/Department in writing how this deficiency is cleared. In-service training will be also provided to all current and future staff members. Copy of the in-service training will be submitted to LPA by POC date
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Based on interview, the licensee did not comply with the section cited above by allowing staff to sleep in residents’ rooms, which poses a potential personal rights risk to persons 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:Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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