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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603549
Report Date: 07/27/2023
Date Signed: 07/27/2023 11:45:22 AM

Document Has Been Signed on 07/27/2023 11:45 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:
07/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver Editha De La CruzTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Glenn Trueman made an unannounced visit and was greeted by Caregiver Editha De La Cruz and explained the reason for the visit.
The purpose of the visit is to complete the required inspection.
Shortly thereafter Administrator Jasfer Cruz arrived.
LPA Trueman toured the facility along with Caregiver Editha De La Cruz today 07/27/2023 at 9:15 AM and the following was observed
Facility contains 4 Client Bedrooms and 2 client bathrooms dining room, kitchen, and TV room.
Hot water temperature measured between 105 F. and 120 F. meeting Title 22 Regulations.
Required Annual Inspection included Infection Control Practices, Operational Requirements, Physical Plant/ Environmental Safety, Staffing, Personnel Records/ Staff Training, Resident Records/ Incident Reports, Resident Rights/ Information, Food Service, Health Related Services, Incidental Medical Services, and Disaster Preparedness.
LPA observed sufficient supply of 2 day perishables and 7 day non perishables.
All staff were cleared and associated.
Visitation signage was posted along with signage for hand washing and proper sanitizing.
Licensee maintained an individual admission agreement for each client.
Fire Clearance has been maintained.
Each client has personal rights free from corporal or unusual punishment, infliction of pain, humiliation, ridicule, coercion, threats, mental abuse, or other actions of a punitive nature.
Program site was clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
Medication was reviewed and was given per physician's directions.
2 Client Files and 11 Staff Files were reviewed.
Interviews were conducted with 2 Staff. 2 client's were in the community at time of visit.

No deficiencies.
Exit interview conducted and copy provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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