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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608404
Report Date: 02/25/2025
Date Signed: 02/25/2025 12:15:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/22/2025 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20250122142449
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:
02/25/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nathaniel Hemedes, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff do not dispense medication as prescribed by physician
Staff do not ensure centrally stored medication is locked
Staff do not refill resident’s medication prescriptions in a timely manner
Staff do not ensure that facility is free of pests
Staff do not ensure that residents are provided with activities
INVESTIGATION FINDINGS:
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During today’s Noncompliance Conference Meeting (NCC), held at the Woodland Hills Regional Office, LPA Panushkina delivered final findings for all allegations mentioned above. LPA met with the Administrator and explained the reason.

On 01/29/2025, LPAs Panushkina and Shahbazian initiated the complaint. LPAs conducted tour of the facility and requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Centrally Stored Medication and Destruction Record (SCMDR), relevant to the investigation. Between 10:20am – 1:00pm, LPAs conducted an interview with the Administrator, two (2) staff and five (5) out of five (5) residents who were able to communicate.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
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 6
Control Number 31-AS-20250122142449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VICTOR JEM HAPPY HOMES
FACILITY NUMBER: 197608404
VISIT DATE: 02/25/2025
NARRATIVE
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Allegation: Staff do not dispense medication as prescribed by physician

It was alleged that R1's eyedrops were not dispensed/given as prescribed. To investigate this allegation, LPAs conducted an interview with the Administrator and requested R1's CSMDR. Review of R1's CSMDR records revealed that the last medication registered on the form (LIC622) was Levothyroxine (date filled on 10/18/24). LPAs also observed that the medication bottle had quantity of 30 pills and the bottle starting date was registered as of 10/25/25. Based on the physician's prescription, the bottle was going to be refilled in November 2024. Moreover, LPAs did not observe any eye drops registered on CSMDR. In addition, LPAs observed two boxes of the same eye drops present in R1's room. During the Interview with the Administrator and S1, LPAs asked to explain how the staff follows the physician's order, when two (2) bottles of the same eyedrops are present, one (1) of which was filled on 09/10/24 and the second eyedrop was filled on 01/10/25. Administrator and S1 were unable to provide any explanation and confirmed that the facility made an error by not always following the physician’s order. Therefore, based on interviews, LPAs record reviews and observation, this allegation is Substantiated.

Allegation: Staff do not ensure centrally stored medication is locked

Upon arrival, LPAs observed a plastic 32qt clear view storage bin placed on a kitchen table. LPAs also observed the bin had R3's sixteen (16) prescribed medications accessible to residents in care. LPAs conducted an interview with the Administrator and were informed that one (1) of the medication cabinet locks is broken and must be replaced, therefore, the staff kept the storage bin on a kitchen table. At 10:15am, LPAs checked the medication cabinet in the kitchen and confirmed that the lock was broken, and all medications were accessible to residents in care. Moreover, LPAs observed five (5) bottles of vitamins on a kitchen table. Interview with the Administrator revealed that the vitamins belong to the staff/Administrator and LPAs were informed that all vitamins will be locked immediately. Lastly, at 10:29am, LPAs observed Ibuprofen bottle with nine (9) tablets, also prescribed to the Administrator, on the top of a drawer, in the living/dining room area accessible to residents in care. Therefore, based on interviews, LPAs observation and inspection, this allegation is Substantiated.

Continue on LIC9099-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20250122142449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VICTOR JEM HAPPY HOMES
FACILITY NUMBER: 197608404
VISIT DATE: 02/25/2025
NARRATIVE
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Allegation: Staff do not refill resident’s medication prescriptions in a timely manner

It was alleged that R1’s eyedrops are not being refilled in a timely manner. To investigate this allegation, LPAs conducted an interview with the Administrator and were informed that the staff contacts R1’s responsible party to refill the eyedrops. Administrator also confirmed that the facility notifies the responsible party regarding the refill, but the medications are not always delivered timely. Moreover, LPAs conducted review of R1's CSMDR records and observed that the last medication registered on the form (LIC622) was Levothyroxine (date filled on 10/18/24). LPAs did not observe any eyedrops registered on CSMDR. In addition, LPAs observed R1’s two boxes of the same eye drops present in R1's room. First eyedrop was filled on 09/10/24 and the second eyedrop was filled on 01/10/25. Each bottle had a quantity of 2.5ML with the instruction to have 1 drop in each eye twice a day. 2.5ML contains approximately fifty (50) drops, and following the physician’s order, each bottle can last only 12.5 days. The last bottle was refilled on 01/10/25 and LPAs observed it to be full. During the interview with the Administrator and S1, LPAs asked to explain the reason why the bottle was still full, when on 01/23/24 the refill was due. Both parties were unable to provide any explanation. Therefore, based on interviews, LPAs record reviews and observation, this allegation is Substantiated.


Allegation: Staff do not ensure that facility is free of pests

To investigate this allegation, LPAs conducted interviews with five (5) residents and four (4) out of five (5) residents confirmed seeing cockroaches at the facility bathrooms and common areas. Moreover, during the physical walk tour, at approximately 10:20am, LPAs observed a cockroach on the wall, in the living room. LPAs asked the staff to exterminate. In addition, at 10:48am, LPAs observed another cockroach in the kitchen wall and in the dining area. Interview with the Administrator confirmed that the facility has pests and LPAs were informed that pest control will be hired. Therefore, based on interviews and LPAs observation, this allegation is Substantiated.

Continue on LIC9099-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 31-AS-20250122142449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VICTOR JEM HAPPY HOMES
FACILITY NUMBER: 197608404
VISIT DATE: 02/25/2025
NARRATIVE
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Allegation: Staff do not ensure that residents are provided with activities

To investigate this allegation, LPAs conducted interviews with five (5) residents and all residents interviewed informed LPAs that the facility has no activities during the day. LPAs were also informed that residents watch TV all day long. During the visit conducted on 01/29/25 from 10:00am to 4:30pm, LPAs observed four (4) residents sitting in the living room and watching TV, and one resident was in their bedroom, sitting on the bed. LPAs conducted an interview with the Administrator who confirmed that the facility has no daily activity scheduled for the residents. Therefore, based on interviews and LPAs observation, this allegation is Substantiated.

Deficiencies issued per Title 22.

Exit interview conducted appeal rights explained and copy of this report provided to the Executive Director.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 31-AS-20250122142449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/26/2025
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care:
c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by:
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Administrator agreed to schedule vendorized training for all staff and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion
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Based on record reviews and interviews, licensee did not comply with the section above failing to administer R1 eyedrops as prescribed. This poses an immediate health and safety risk to residents in care.
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Type A
02/26/2025
Section Cited
CCR
87465(h)(2)
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Incidental medical and dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place...
This requirement is not met as evidenced by:
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Administrator agreed to schedule vendorized training for all staff and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion
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Based on observation and interview the licensee did not comply with the section cited above by not assuring medications for R5 and the Administrator are kept locked and inaccessible to residents which poses an immediate health, safety or 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20250122142449
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2025
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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The Administrator will take all measures to maintain the facility free from cockroaches. Administrator will submit updated documentation of Pest Control service agreement to LPA by POC date.
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Based on inspection, and observation the Licensee did not ensure that the facility is safe and sanitary for wellbeing of residents and others. LPA observed cockroaches in the living room, dining room and kitchen areas. This poses a potential health, safety risk and personal rights violation to residents in care.
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Type B
04/01/2025
Section Cited
CCR
87219(a)(1)(A-D)
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Residents shall be encouraged to maintain and develop their quality of life... The activities made available shall include: (1) Socialization to promote or enhance personal relationships. Activities may include, but are not limited, to:
This requirement is not met as evidenced by:
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The Administrator will conduct an in-service meeting with all staff regarding this regulation and provide a daily activity to all residents. Copy of the training will be submitted to LPA by POC date
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Based on LPAs observation, the licensee did not comply with the section cited above by not providing planned activities. During the visit conducted on 01/29/25, LPAs observed five out of five residents watching TV from 10:00am-4:30pm. This poses a potential health, safety risk and personal rights violation 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6