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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603549
Report Date: 07/15/2024
Date Signed: 07/15/2024 02:06:37 PM

Document Has Been Signed on 07/15/2024 02:06 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 HOME CAREFACILITY NUMBER:
198603549
ADMINISTRATOR/
DIRECTOR:
CRUZ, JASFERFACILITY TYPE:
735
ADDRESS:15526 VIRGINIA AVETELEPHONE:
(562) 291-2726
CITY:PARAMOUNTSTATE: CAZIP CODE:
90723
CAPACITY: 4CENSUS: 2DATE:
07/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Willie Lajara - LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
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Licensing Program Analysts (LPA) Luis Mora conducted an unannounced annual visit using the CARE Tool. LPA met with Willie Lajara (Licensee) and explained the reason for the visit. The facility is licensed to serve 2 ambulatory and 2 non-ambulatory clients in the age range of 18 through 59. Facility is operating within the scope of its license.

A tour of the single-story facility included: living room, kitchen, dining area, staff office, 4 client bedrooms, 2 client bathrooms, attached garage, front yard, and backyard. LPA Mora conducted the tour with Willie Lajara 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. Sharps are kept locked in a kitchen cabinet. The First Aid kit is kept locked in the medication closet. The First Aid kit was fully stocked with all required items including a current manual. Cleaning and chemical solutions are kept locked in a bathroom cabinet. Dining and living room have sufficient lighting and sitting area. Medications are centrally stored in a locked hallway closet. All bedrooms have all required furniture, lighting, and bedding. There are clean linen and towels in each room closet. All bathrooms were observed with non-skid material. Water temperature was tested at 118.9 degrees F, which is within the required 105-120 degrees F. A fire extinguisher was observed in the dining area, and it is fully charged. Smoke detectors combined with carbon monoxides were observed throughout the facility and in each room and were operable during the visit. Client and staff files will be kept locked in the medication closet. The front yard and backyard are clean, and there is a shaded sitting area in the backyard. No bodies of water were observed at the facility. Passageways and exits are free of obstruction. LPA reviewed medication for 2 clients and observed that medication was given as prescribed. LPA reviewed files for 2 clients and 5 staff. LPA observed administrator certificate for Jasfer Cruz - 6013156735 with an expiration date of 03/07/2025. LPA reviewed P&I funds for 1 client and a staff was present. The other client does not have P&I funds at the facility. The facility has a valid surety bond.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there was no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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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