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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604677
Report Date: 05/04/2022
Date Signed: 05/04/2022 12:42:10 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
04/11/2022 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20220411145112
FACILITY NAME:JW CARE HOMEFACILITY NUMBER:
197604677
ADMINISTRATOR:JOSEPHINE WASSELFACILITY TYPE:
740
ADDRESS:37944 MOONDANCE DRIVETELEPHONE:
(661) 285-3255
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY:5CENSUS: 3DATE:
05/04/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jojomaureli Salamero, Administrator TIME COMPLETED:
01:05 PM
ALLEGATION(S):
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Resident is not afforded proper living accomodations
INVESTIGATION FINDINGS:
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At 12:00pm Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility mentioned above to conduct a subsequent complaint visit. Upon arrival, LPA was greeted by staff, and later met with the Administrator Jojomaureli Salamero and an entrance interview was conducted.

On 4/21/22 LPAs Angela Panushkina and Shira Stamps conducted an inital 10-day visit to investigate the allegations. During that visit, LPAs conducted interviews with the Administrator, one (1) staff, three (3) residents and R1's Power of Attorney (POA).

Allegation - Resident is not afforded proper living accomodations
As of February 9th 2022, R1's Admission Agreement indicates that R1 will be receiving care and supervision at the above mentioned facility. However, an interview with the Administrator revealed that R1's POA asked the Administrator to take R1 away from the facility for couple of days due to R1's POA's expressing concern that another family member might take R1 out of the facility against their will. Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
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 3
Control Number 31-AS-20220411145112
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: JW CARE HOME
FACILITY NUMBER: 197604677
VISIT DATE: 05/04/2022
NARRATIVE
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Administrator admitted that R1 stayed at the Administrator's primary residence for 2 days, where R1 was provided and unlicensed care and supervision. In addition, LPA conducted an interview with R1's POA where the POA confirmed that they asked the Administrator to remove R1 from the facility. Based on interviews conducted with the Administrator and R1's POA this allegation is Substantiated.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20220411145112
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: JW CARE HOME
FACILITY NUMBER: 197604677
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2022
Section Cited
CCR
87468.2(a)(14)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (a) In addition to the rights listed in Section 87468.1... (14) To reasonable accommo-dation of their individual needs and preferences in all aspects of life...

This requirement is not met as evidenced by:
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Licensee/Administrator will submit a written explanation to the department regarding their actions and how such actions will be prevented in a future.
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Based on an interview with the Administrator, the licensee did not comply with the section cited above and allowed R1 to stay at the Administrator's primary residence where an unlicensed care and supervision was provided, which poses a potential health and safety risk to person 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: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3