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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607183
Report Date: 06/15/2026
Date Signed: 06/15/2026 12:36:53 PM

Document Has Been Signed on 06/15/2026 12:36 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:AVENUE "H" GUEST HOME, INC.FACILITY NUMBER:
197607183
ADMINISTRATOR/
DIRECTOR:		JOEL FLETCHERFACILITY TYPE:
735
ADDRESS:3640 AVENUE H-13TELEPHONE:
(661) 916-7507
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
06/15/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Belinda Renee HicksTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 06/15/2026, Licensing Program Analysts (LPAs) Lorena Casillas and Evelin Rios conducted an unannounced case management visit. LPA met with the Administrator Belinda Rene Hicks and disclosed the reason for the visit.

Today’s case management visit is to follow on an unusual incident previously reported on 06/02/26 by the facility in which Client #1 (C1)’s hair was allegedly pulled by Staff #1 (S1). The purpose of the visit is to obtain additional information regarding this incident. Between 10:00am to 12:00 pm LPA interviewed Administrator and two (2) staff.

It was reported that on 06/01/26 C1 had a behavior episode where C1 kept banging their head during a behavior episode. Due to this behavior S1 allegedly pulled C1’s hair, however based on Special Incident Report (SIR) it was reported that an internal investigation was conducted and the alleged incident did not take place as originally assumed. LPAs interviewed Administrator who stated that C1 was in fact having a behavior where C1 kept banging their head against the wall, this is documented behavior for C1. However, Administrator stated that S1 denied pulling C1’s hair, instead S1 explained that in order to prevent C1 from injuring their head, S1 attempted to place their hand as a barrier between C1’s head and the wall, to minimize injury. As S1 was reaching for C1’s head, S1’s hand was tangled in C1’s hair. The Administrator further stated that it was S1’s immediate reaction to prevent C1 from causing self injury. Normally staff grab a pillow to minimize injury, but the incident happened so fast that S1 simply reacted as best they could to make sure that C1’s head was not injured.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: AVENUE "H" GUEST HOME, INC.
FACILITY NUMBER: 197607183
VISIT DATE: 06/15/2026
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LPA attempted to interview S1 over the phone but was not able to speak to S1. LPAs interviewed S2 who repeated what Administrator stated, adding that S1 did not purposefully pull on C1’s hair, it was simply S1 helping C1 during a behavior where S1’s hand was used to avoid injury. LPA interviewed S3 over the phone and S3 stated that they did not witness the initial behavior, S3 witnessed S1’s hand in C1’s hair and perceived it as possible hair pulling. Facility is working with behavioral staff and NLARC to try to manage and minimize C1’s behavior, in the interim staff continue to use C1’s behavioral plan to avoid continued behaviors. LPA attempted to interview C1, however C1 is not able to communicate with LPA. The facility has sent appropriate special incident reports to Community Care Licensing, Adult Protective Services, and North Los Angeles Regional Center. LPA reviewed C1’s IPP and behavioral plan and observed that C1’s needs are being met and plans are being followed by staff.

Since the Administrator has taken the appropriate actions to ensure staff are appropriately caring for C1 and that protocols are being followed for C1’s behaviors, there are no deficiencies cited at this time.

No deficiencies cited. Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2026
LIC809 (FAS) - (06/04)
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