197604677-2-23-2022-31-AS-APAA-CBWSTQ-20220223130955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604677
Report Date: 02/23/2022
Date Signed: 02/23/2022 01:10:50 PM

Document Has Been Signed on 02/23/2022 01:10 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:	JW CARE HOME		FACILITY NUMBER:	197604677
ADMINISTRATOR:	JOSEPHINE WASSEL		FACILITY TYPE:	740
ADDRESS:	37944 MOONDANCE DRIVE		TELEPHONE:	(661) 285-3255
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93552
CAPACITY:	5	CENSUS: 5	DATE:	02/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jojomaureli Salamero, Administrator		TIME COMPLETED:	01:30 PM

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At 10:00am Licensing Program Analyst (LPA) Angela Panushkina, conducted an unannounced annual inspection at the above facility. LPA met with the Administrator, Jojomaureli Salamero, who granted access to home, and LPA explained the reason for the visit.

LPA toured the entire facility with the Administrator, and observed the following:

This is a 5 bedroom, 2 bathroom, single story family residence that includes a living room, dining area, kitchen and attached garage.

Infection control: Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff.

Kitchen: At approximately, 10:34am LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. At 10:45am LPA observed insulin in kitchen refrigerator unlocked and accessible to residents. All knives and sharps are observed to be locked and inaccessible to residents.

Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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: JW CARE HOME	FACILITY NUMBER: 197604677
	VISIT DATE: 02/23/2022

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Bathrooms: At 11:30am LPA observed all bathrooms are clean and in good repair. The hot water temperature measured at 135.1°F. LPA observed appropriate grab bar and non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom.

Common Areas: The facility maintains a comfortable temperature at 76°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. There is a fire extinguisher in the kitchen and it was last serviced on 04/15/21.

Outside areas: At approximately, 11:00am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:07am they were tested and observed to be operational.

The garage: Laundry area is located in an attached garage. Garage is also being used for an extra food and PPE storage. LPA observed all chemicals being locked and inaccessible to residents.

Medications: At approximately, 10:50am LPA observed medications are centrally stored and locked in a hallway cabinet and inaccessible to residents in care.

Administrative: Administrator will email a copy of Liability Insurance and LIC.500.

Deficiencies issued per Title 22.

Appeal rights issued.

Exit interview conducted. Copy of this report emailed to Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/23/2022 01:10 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: JW CARE HOME	FACILITY NUMBER: 197604677
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintanance ond Oparation. Hot water provided for use of residets shall be maintained between 105 and 120 degrees Fahrenheit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and the interview with the Administrator, the licensee did not comply with the section cited above. The hot water temperature was measured at 135.1°F which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/23/2022
	Plan of Correction
1 2 3 4	Administrator agreed to make a water log showing 8am - 6pm readings. A copy of the log for two weeks begining on 02/23/22 shall be submitted to LPA to clear the deficiency.

Type A

Section Cited

CCR

87465(h)(2)

87465(h)(2) Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by storing/keepimg the insulin in the kitchen refrigerator unlocked and accessible to residents, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 02/24/2022
	Plan of Correction
1 2 3 4	The Administrator agreed to place all medications that need to be in the refrigerator in a locked box in both refrigerators on the premises. A declaration on how this will not be repeated again shall be submitted to LPA by POC date.

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC809 (FAS) - (06/04)

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