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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603549
Report Date: 06/26/2023
Date Signed: 06/26/2023 08:58:11 AM

Document Has Been Signed on 06/26/2023 08:58 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 CAREFACILITY NUMBER:
198603549
ADMINISTRATOR:CRUZ, JASFERFACILITY TYPE:
735
ADDRESS:15526 VIRGINIA AVETELEPHONE:
(562) 291-2726
CITY:PARAMOUNTSTATE: CAZIP CODE:
90723
CAPACITY: 4CENSUS: 2DATE:
06/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Administrator Jasfer CruzTIME COMPLETED:
09:10 AM
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Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced case management visit to the facility. The purpose of today’s visit was to serve the Order to Licensee of Immediate Exclusion from Facility for Staff #1 (S1). An investigation by the California Department of Social Services was conducted and it was determined that S1 violated California Code of Regulations Title 22 for personal rights.

On today's visit LPA met with Administrator Jasfer Cruz and explained the reason for the visit. Administrator was provided with copies of the Order to Licensee of Immediate Exclusion and Order to Individual for Immediate Exclusion letters and Government Code 11522.

Exit interview held. A copy of the report was provided to administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2023
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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