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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604677
Report Date: 07/06/2022
Date Signed: 07/06/2022 11:54:07 AM


Document Has Been Signed on 07/06/2022 11:54 AM - 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 HOMEFACILITY NUMBER:
197604677
ADMINISTRATOR:JOJOMAURELI SALAMEROFACILITY TYPE:
740
ADDRESS:37944 MOONDANCE DRIVETELEPHONE:
(661) 285-3255
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY:5CENSUS: 3DATE:
07/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:JOJOMAURELI B. SALAMERO, ADMINISTRATORTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced case management visit to the above facility. LPA was greeted by a staff member, Laura Escobar, who granted access to home. Administrator arrived shortly after and LPA explained the reason for the visit.
  • On 06/24/22 the Department received a notification that the Licensee, Josephine Wassel, passed away on 06/22/22.
  • The Centralized Application Bureau received a new application along with the fee on 06/27/22 and is in a pending process until further notification.
  • On 07/01/22 a meeting was scheduled at the Regional Office with the Administrator to discuss the Health and Safety Code, Regulations and the Administrator was also informed that the Department issued Emergency Approval To Operate for up to 60 days pending issuance or denial of a license.

During today's visit LPA conducted a tour of the facility and confirmed that the home continues to provide care and supervision to three (3) residents. LPA also observed the home to be clean and have sufficient food supply.

Exit interview conducted and the copy of this report issued to the Administrator.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2022
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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