<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603549
Report Date: 08/04/2025
Date Signed: 08/04/2025 12:11:57 PM

Document Has Been Signed on 08/04/2025 12:11 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
MONTEREY PARK ASC, 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: 1DATE:
08/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Edith De La Cruz, Direct Support ProfessionalTIME VISIT/
INSPECTION 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), Mayra Cota, conducted an unannounced annual visit with Editha De La Cruz, Direct Support Professional and Jaspher Cruz, Administrator. The reason for the visit was explained. 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. Clients receive services through the South Central Regional Center. Facility is located in a residential neighborhood of Paramount, CA.

A tour of the single-story facility included: living room, kitchen, dining area, staff office, (4) client bedrooms, (2) client bathrooms, attached garage, outdoor laundry area, front and back yard. LPA Cota, conducted the tour of the facility with Editha De La Cruz, DSP, and observed the following: kitchen was observed clean and sanitary. Appliances were operating during the time of visit; however, facility did not have a sufficient 2 day supply of perishable food. Sharps are kept locked in a kitchen cabinet. Cleaning and chemical solutions are also kept locked in a bathroom cabinet. Dining and living room have sufficient lighting and sitting area. All bedrooms have the required furniture, lighting, and bedding. Linen closet in the hallway has extra linen supplies and toiletries for clients. All bathrooms were observed to have non-skid surfaces and grab bars. Water temperature was tested and measured at 114.3 in bathroom #1 and 116.4 in bathroom #2, which is within the required 105-120 degrees F. A charged fire extinguisher was observed in the dining area and was last inspected on 3/3/25. The front yard and backyard are clean, and there is a shaded patio area in the backyard. No bodies of water were observed at the facility. Walkways and exits were observed clear of debris and obstructions. Combination smoke and carbon monoxide detectors were observed throughout the facility and were operable during the visit. Client and staff files are kept locked in the staff office. Four (4) client files were observed, however, (1) client file is missing the Physician's Report.
****Continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
Document Has Been Signed on 08/04/2025 12:11 PM - It Cannot Be Edited


Created By: Mayra Cota On 08/04/2025 at 11:12 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 HOME CARE
FACILITY NUMBER: 198603549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observatio, the licensee did not comply with the section cited above by not having sufficient 2-day perishable food which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2025
Plan of Correction
1
2
3
4
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.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/04/2025 12:11 PM - It Cannot Be Edited


Created By: Mayra Cota On 08/04/2025 at 11:12 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 HOME CARE
FACILITY NUMBER: 198603549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having (1) client's Physician's Report (medical assessment) on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2025
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having (1) client's Physician'r Report (medical assessment) on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/04/2025
Plan of Correction
1
2
3
4
POC corrected at the time of visit. Administrator provided LPA, proof of TB for (1) client via email during visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JASWILL HOME CARE
FACILITY NUMBER: 198603549
VISIT DATE: 08/04/2025
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
26
27
28
29
30
31
32
LPA reviewed (4) staff flies and contained the proper background clearances and associations to the facility. Medications are centrally stored in a locked hallway closet. LPA reviewed medication for (2) clients and observed that medication was given as prescribed and documented accordingly. First Aid kit was inspected and found to have the proper tools and manual.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies were observed and cited today. Exit interview held with Jasfer Cruz, Administrator and a copy of the report and Appeal Rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5