198602596-9-28-2022-28-AS-LMOA-CJPQA4-20220928115920

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602596
Report Date: 09/28/2022
Date Signed: 09/28/2022 11:59:28 AM

Document Has Been Signed on 09/28/2022 11:59 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 BROOKMILL		FACILITY NUMBER:	198602596
ADMINISTRATOR:	CRUZ, JASFER		FACILITY TYPE:	735
ADDRESS:	7822 BROOKMILL RD		TELEPHONE:	(562) 381-0242
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY: 4		CENSUS: 4	DATE:	09/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Jasfer Cruz - Administrator		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit at the facility with focus on the infection control domain, medication and food review. LPA Mora met with Jasfer Cruz - Administrator and explained the reason for the visit. The facility is licensed to serve four non-ambulatory clients ages 18-59. Facility currently has 3 non-ambulatory and 1 ambulatory clients serviced by South Central Los Angeles Regional Center. The facility is in a residential area and it is a one story family home. A tour of the single-story facility included the office room, kitchen, dining area, living room, 4 client bedrooms, 1 client bathroom, 1 staff restroom, front yard, backyard, and attached garage. LPA Mora conducted the tour with Jasfer Cruz and observed the following: sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen and refrigerator in the garage. Sharps were observed locked in a kitchen cabinet. Chemical and cleaning solutions are kept locked in the staff restroom cabinet. The First Aid kit is kept locked in the medication cabinet and it is fully stocked with all required items including a current manual. Clean towels and extra clean linen were observed in the hallway cabinet. Dining and living room have sufficient lighting and sitting area. Medications are kept locked in a cabinet in the living room. Client and staff files are kept locked in the office area. All bedrooms have all required furniture, lighting, and bedding. The client bathroom was observed with grab bars and shower mats. The water temperature was tested in the client bathroom and staff restroom and measured at 145.7.2 degrees F and 147.9 degrees F, which is not within the required 105-120 degrees F. A fire extinguisher was observed in the living room and it is fully charged. Smoke detectors and carbon monoxides were observed throughout the facility and were operable during the visit. The front yard and backyard are clean. There is a shaded area with seating in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction. (CONTINUED TO LIC 809C)

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JASWILL BROOKMILL	FACILITY NUMBER: 198602596
	VISIT DATE: 09/28/2022

NARRATIVE

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LPA reviewed medication for 4 clients and observed that medications are documented properly and given as prescribed. LPA reviewed files for all 4 clients and 4 staff. No issues were found with the files. LPA observed administrator certificate for Jasfer T Cruz - 6013156735 with an expiration date of 03/07/2023.

Facility has 30 days supplies of Personal Protective Equipment in the garage and a kitchen cabinet. Facility is following COVID-19 recommendations regarding screening visitors, staff, and clients. Covid-19 prevention signs are posted throughout the facility and hand-washing signs were observed in the bathrooms. Sufficient hand soap, hand sanitizer, and paper towels were observed.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was one deficiency observed during the visit (Refer to LIC 809D). Exit interview held and a copy of the report and appeal rights was provided.

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/28/2022 11:59 AM - It Cannot Be Edited

Created By: Luis Mora On 09/28/2022 at 11:32 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JASWILL BROOKMILL	FACILITY NUMBER: 198602596
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). 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 in 2 out of 2 bathroom/restroom which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/29/2022
	Plan of Correction
1 2 3 4	Administrator will adjust water temperture by today and measure the temperature for a week in a log. Administrator will submit water temperature log to LPA by 10/05/22. ***Administrator adjusted the water temperature during the visit and it measure at 96 degrees F. Administrator will continue to adjust the water temperature until it is beteween 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Stefanie Coronel

LICENSING EVALUATOR NAME:

Luis Mora

LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022

LIC809 (FAS) - (06/04)

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