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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602060
Report Date: 06/07/2022
Date Signed: 06/07/2022 10:35:38 AM

Document Has Been Signed on 06/07/2022 10:35 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JASWILL HOME CARE IIFACILITY NUMBER:
198602060
ADMINISTRATOR:CRUZ,JASFERFACILITY TYPE:
735
ADDRESS:13054 ARDIS AVETELEPHONE:
(562) 396-0418
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 4CENSUS: 3DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jasfer Cruz; AdministratorTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator Jasfer Cruz and explained the reason for the visit. Physical Plant was toured, medications were reviewed, and food supply was inspected.

The following was observed/inspected:
  • LPA and Mr. Cruz toured the home and inspected (4) bedrooms, (2) full bathrooms, dining room, kitchen, living room, family room, office area, detached garage, and backyard shaded patio area with required furniture. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and bathroom #2 and measured between 112F - 115F which is within the required 105F - 120F degrees. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. Carbon Monoxide detector is located in the hallway of the home. There is a fire extinguisher located in the kitchen which is fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to clients. Cleaning supplies and disinfectants are locked under the sink and are inaccessible to clients. First Aid kit was fully stocked with current manual.
  • Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
  • Staff were observed wearing masks and screening visitors at entry.
  • Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
  • (3) out of the (3) client medications were reviewed. Medications are centrally stored in a cabinet located in the office area. Medications are documented properly and given as prescribed.
  • Staff and Client files were not reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: David Sicairos
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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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