197604677-8-6-2022-31-AS-NMAN-CJAU2J-20220915151202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197604677
Report Date: 08/06/2022
Date Signed: 08/06/2022 04:34:47 PM

Unsubstantiated

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
01/06/2021 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20210106160623

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: 4	DATE:	08/06/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Maricel Erana		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility staff did not make disinfectants inaccessible to residents.
Facility staff did not make medications inaccessible to residents.
Facility staff did not discard contaminated food.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. LPA arrived at 12:30 PM. Upon entry, LPA met with the administrator, Jojomaurali Salamero, and caregiver Maricel Erana, was offered sanitizer, screened for COVID 19, and signed in. At the time of the visit, there were two staff and four residents present. The Administrator designated Maricel Erana as the responsible staff member to sign and accept this report.

---Facility staff did not make disinfectants inaccessible to residents.

It was alleged that staff left disinfectant on top of the toilet and sink unlocked. To investigate this allegation, on 08/06/2022 at 12:50 PM, LPA conducted a physical plant tour and, from 1:30 PM – 3:00 PM, interviewed two staff and two residents.

(Cont. on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210106160623

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: 08/06/2022

NARRATIVE

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LPA’s observations from the physical plant tour revealed there were no cleaning supplies left unattended and that all toxins are locked away in a storage cabinet located in the kitchen. Furthermore, during interviews, staff stated that they do not leave cleaning supplies unattended and, when not in use, cleaning supplies are locked away. In addition, residents also stated that they do not see cleaning supplies left unattended. Based on the observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Facility staff did not make medications inaccessible to residents.

It was alleged that resident's medication was in a medication cup at resident's bedside while staff was not present. To investigate this allegation, on 08/06/2022 at 12:50 PM, LPA conducted a physical plant tour and, from 1:30 PM – 3:00 PM, interviewed two staff and two residents. LPA’s observations from the physical plant tour revealed there were no medications left unattended in any of the room and that all medication are stored in a locked storage cabinet located in the hallway. Furthermore, during interviews, staff stated that they do not leave medication unattended. In addition, residents also stated that staff do not leave medications unattended and that staff are present until medications have been completely administered. Based on the observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Facility staff did not discard contaminated food.

It was alleged that facility has spoiled individual cartons of milk, single size yogurt and large tub of yogurt that are expired. To investigate this allegation, on 08/06/2022 at 12:50 PM, LPA conducted a physical plant tour and, from 1:30 PM – 3:00 PM, interviewed two staff and two residents. LPA’s observations from the physical plant tour revealed there were no expired items of food in the refrigerator, freezer or pantry. Furthermore, during interviews, staff stated that they do not keep expired foods in the facility and that they are discarded immediately. In addition, residents also stated that they have no had any experience with eating spoiled foods. Based on the observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.
Exit interview was conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2022

LIC9099 (FAS) - (06/04)

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