198603549-8-11-2023-28-AS-RORN-CVEMC5-20230906092856

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603549
Report Date: 08/11/2023
Date Signed: 08/11/2023 12:08:51 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2023 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230519084609

FACILITY NAME:	JASWILL HOME CARE		FACILITY NUMBER:	198603549
ADMINISTRATOR:	CRUZ, JASFER		FACILITY TYPE:	735
ADDRESS:	15526 VIRGINIA AVE		TELEPHONE:	(562) 291-2726
CITY:	PARAMOUNT	STATE: CA	ZIP CODE:	90723
CAPACITY:	4	CENSUS: 2	DATE:	08/11/2023
		UNANNOUNCED	TIME BEGAN:	08:23 AM
MET WITH:	Jasfer Cruz (Administrator)		TIME COMPLETED:	12:22 PM

ALLEGATION(S):

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Facility did not seek medical attention for client.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegation. LPA met with Jasfer Cruz (Administrator) and explained the reason for the visit.

The investigation consisted of the following: On 05/25/2023, LPA Mora obtained copies of the client and staff rosters and interviewed Administrator, Facility Co-owner, Staff 1 (S1), Director of Client 1 (C1) Day Program, and Client 1 (C1) family member. LPA also obtained copies of Client 1 (C1) physician report and Individual Program Plan (IPP). On 06/07/2023, LPA communicated with Regional Center Representative via email. Today's visit, LPA interviewed Administrator at the facility, Client 1 (C1) via phone, and Client 2 (C2) and Client 3 (C3) at their Adult Day Program.

The investigation revealed the following: regarding the allegation "facility did not seek medical attention for client", it is alleged that C1's residential facility did not seek medical attention for the client who was expressing abdominal pain. (Continued to LIC 9099-C)

Substantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 28-AS-20230519084609

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 198603549
	VISIT DATE: 08/11/2023

NARRATIVE

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Interviews conducted revealed that on the night of 05/14/2023 C1 had a stomachache and facility staff were aware of it. Interview with C1 revealed that C1 vomited, had diarrhea and extreme stomach pain. On the morning of 05/15/2023, C1 left to the Adult Day Program and staff at the Adult Day Program had to send C1 to the emergency room due to stomach pain. C1 received a CAT scan in the hospital and determined C1 needed a surgery due to intestine being tied and was unable to pass bowel movement. The other 2 clients could not corroborate the allegation due to being non-verbal. Regional Center conducted their own investigation and the facility was issued a corrective action plan on 6/6/2023 due to a supported outcome of Alleged Neglect: failure to provide medical care.

Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 1 are being cited on the attached LIC 9099-D. Exit interview held and a copy of the report and appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20230519084609

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 198603549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/12/2023 Section Cited CCR 80075(a)	1 2 3 4 5 6 7	80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.	1 2 3 4 5 6 7	Facility is to ensure that Title 22 Section 80075 regulations are met at all times. Additionally, an in-service training is to be conducted regarding Title 22 Section 80075 and a training log with staff signature submitted to CCLD by 08/18/2023.
	8 9 10 11 12 13 14	This requirement is not met by: Based on interviews and records review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Facility did not seek medical attention for Client 1 (C1).	8 9 10 11 12 13 14	During the visit, Administrator provided LPA with an in-service training regarding this issue that was conducted on 06/17/2023
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/19/2023 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230519084609

FACILITY NAME:	JASWILL HOME CARE		FACILITY NUMBER:	198603549
ADMINISTRATOR:	CRUZ, JASFER		FACILITY TYPE:	735
ADDRESS:	15526 VIRGINIA AVE		TELEPHONE:	(562) 291-2726
CITY:	PARAMOUNT	STATE: CA	ZIP CODE:	90723
CAPACITY:	4	CENSUS: 2	DATE:	08/11/2023
		UNANNOUNCED	TIME BEGAN:	08:23 AM
MET WITH:	Jasfer Cruz (Administrator)		TIME COMPLETED:	12:22 PM

ALLEGATION(S):

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Facility does not have sufficient staffing to meet client's needs.

INVESTIGATION FINDINGS:

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3
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5
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13

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegation. LPA met with Jasfer Cruz (Administrator) and explained the reason for the visit.

The investigation consisted of the following: On 05/25/2023, LPA Mora obtained copies of the client and staff rosters and interviewed Administrator, Facility Co-owner, Staff 1 (S1), Director of Client 1 (C1) Day Program, and Client 1 (C1) family member. LPA also obtained copies of Client 1 (C1) physician report and Individual Program Plan (IPP). On 06/07/2023, LPA communicated with Regional Center Representative via email. Today's visit, LPA interviewed Administrator at the facility, Client 1 (C1) via phone, and Client 2 (C2) and Client 3 (C3) at their Adult Day Program.

The investigation revealed the following: regarding the allegation "facility does not have sufficient staffing to meet client's needs", it is alleged that C1's family member was told that there are no staff to watch C1 when not in day program. (Continued to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20230519084609

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 198603549
	VISIT DATE: 08/11/2023

NARRATIVE

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Administrator and staff interviewed denied the allegation. They stated that when all clients leave to the Adult Day Program then the staff don't stay at the facility. However, if a client wants or needs to stay at the facility then a staff or the administrator will stay with them, and this has happened in the past. C1 stated that C1 did not want to go to the Adult Day Program on 05/15/2023 because C1 was not feeling well, but staff told C1 that there wasn't going to be staff at the facility to take care of C1. Administrator and staff stated that they did not tell C1 that there wasn't going to be any staff available to take care of C1 and that C1 told the morning staff that C1 wanted to go to the Adult Day Program because C1 was feeling well. The other 2 clients could not corroborate the allegation due to being non-verbal. Interviewed with C1's family member revealed that she doesn’t know if staff told C1 that they did not have emergency staff to take care of C1. She just heard it from C1. LPA asked C1's family member if C1 has stayed at the facility in the past with staff, and C1's family member stated yes. C1's family member confirmed that staff have stayed with C1 at the facility in the past because C1 was extremely sick. Regional Center conducted their own investigation and the allegation of facility not following staff ratio was found not supported. LPA reviewed the facility's Personnel Report and observed that the facility has sufficient staff to meet the clients' needs.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview held and a copy of the report was provided

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5