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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608404
Report Date: 02/03/2024
Date Signed: 02/03/2024 04:29:44 PM


Document Has Been Signed on 02/03/2024 04:29 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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: 3DATE:
02/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Nathaniel Hemedes, AdministratorTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Abeye Duguma met with the administrator, Nathaniel Hemedes, for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 12:40 PM and the following was noted:

There is one entrance being utilized at the facility. The facility has a total of three (03) resident bedrooms and two (02) bathrooms. The facility is fire cleared for six (06) non-ambulatory. The facility is currently occupying three (03) non-ambulatory residents.

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for storage. Laundry detergents, cleaning agents and other toxins are locked away.

Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

The living and dining room are neat and clean. The facility maintains a comfortable temperature at 70°F. The smoke and carbon monoxide were NOT observed to be operational. The detector in the hallway and rear entrance are missing. Facility is equipped with pull alarm. Fire extinguisher is located near the kitchen, observed to be full and last purchased 08/12/2019.

(continued on LIC 809-C)

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/03/2024
NARRATIVE
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The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 113.2°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

LPA observed medication and first aid kit to be locked and inaccessible to residents.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No other health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/03/2024 04:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the smoke and carbon monoxide detectors in the hallway and rear exit are missing, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Facility shall install smoke detectors in missing areas immediately.
Type A
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the smoke detectors are not operational which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2024
Plan of Correction
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Facility shall install smoke detectors in missing areas immediately.
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: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2024
LIC809 (FAS) - (06/04)
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