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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602596
Report Date: 11/28/2023
Date Signed: 11/28/2023 05:34:08 PM

Document Has Been Signed on 11/28/2023 05:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JASWILL BROOKMILLFACILITY NUMBER:
198602596
ADMINISTRATOR:CRUZ, JASFERFACILITY TYPE:
735
ADDRESS:7822 BROOKMILL RDTELEPHONE:
(562) 381-0242
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 4CENSUS: 3DATE:
11/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Jasfer Cruz - AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced case management visit due to an incident reported to Licensing on 11/3/2023. LPA met with Imelda Madregal, Direct Support Professional I (DSP I) and Jhoanna Fernandez, Direct Support Professional I & II (DSP I & II) and explained the purpose of today's visit. The Administrator was called and arrived at 3:15pm and LPA discussed the purpose of the visit.

The incident report stated that on 11/2/2023, Staff #1 (S1) informed facility administrators that she witnessed physical abuse towards Client #1 (C1). S1 stated that the incident happened on 10/27/2023 when she saw Staff #2 (S2) in the living room flicked C1’s mouth because C1 was being loud. S1 stated that she saw S2 did it again in the afternoon for a second time. S1 also stated that she did not report it immediately because she was fearful of retaliation from S2.

Per the Administrator, as soon as he was informed of the incident, he reported it to CCLD and SCLARC immediately. The Administrator stated that they conducted an internal investigation and determined that there was a suspected abuse incident that happened on 10/27/2023. Administrator also suspended S2 and was not allowed to come back to work until further notice or until investigation is completed. Along with CCLD and SCLARC, C1’s family member was also notified. Administrator conducted a body check on C1 and indicated that C1 did not suffer injury. Another staff, Staff #3 (S3) told the Administrator that there was another incident that happened on 10/26/2023 while she was in the kitchen. S3 heard a smack/slap sound coming from the living room where S2 and C1 were. S3 did not see it happened but indicated that she was sure that S2 slapped C1.

Based on the information gathered, there is sufficient evidence of violating the clients’ personal rights.

Deficiency cited on the attached LIC 809D. An exit interview was conducted, and a copy of this report was provided to Jasfer Cruz, Administrator along with the Appeals Rights.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2023
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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Document Has Been Signed on 11/28/2023 05:34 PM - It Cannot Be Edited


Created By: Bennette Pena On 11/28/2023 at 02:56 PM
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: 11/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2023
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights..(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain..mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions... medication or aids to physical functioning.

This requirement was not met as evidenced by:
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The administrator shall ensure that the clients’ personal rights are protected and re-train all staff providing care regarding Zero Tolerance Policy, Clients Personal Rights and Mandated Reporting Protocol and Timelines. Administrator/Licensee shall develop a written Plan of Correction to ensure compliance with CCR Title 22, Section 80072(a)(3) and submit verification of training & written POC to CCL/LPA by POC due date.

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Interviews conducted with the staff revealed that S1 had witnessed S2 flicked a client’s mouth twice. S3 also stated that a similar incident happened when S3 heard a slapping sound while S2 was looking after C1. This poses an immediate Health, Safety or Personal Rights risk to the clients 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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023


LIC809 (FAS) - (06/04)
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