198603549-1-18-2024-28-AS-RORN-CZYMAL-20240130082628

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603549
Report Date: 01/18/2024
Date Signed: 01/18/2024 02:51:29 PM

Unsubstantiated

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
01/09/2024 and conducted by Evaluator Luis Mora

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240109095611

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:	01/18/2024
		UNANNOUNCED	TIME BEGAN:	09:12 AM
MET WITH:	Jasfer Cruz - Administrator		TIME COMPLETED:	03:06 PM

ALLEGATION(S):

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Facility staff pushed resident causing them to fall on the floor.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced 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: LPA Mora obtained copies of the client and staff rosters, reviewed Client 1 (C1) entire file, interviewed Administrator, Staff 1 - Staff 2 (S1 - S2), Lakewood Police Department Secretary, Regional Center Service Coordinator, Regional Center Quality Assurance, and attempted to interview Staff 3 (S3) via phone. LPA conducted a collateral visit at Client 1 (C1) and Client 2 (C2) Adult Day Program and interviewed both clients and 3 ADP staff.

The investigation revealed the following: regarding the allegation "facility staff pushed resident causing them to fall on the floor", it is alleged that C1 stated that "papa" pushed C1 down and fell to the floor causing C1 to hit shoulder with the floor. C1 also stated that "papa" works at the facility. (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: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240109095611

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: 01/18/2024

NARRATIVE

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Administrator and staff denied the allegation. Administrator stated that C1 calls all male staff papa. He also stated that C1 tends to consistently make this kind of false allegations. Regional Center Quality Assurance stated that they visited the facility to follow up on this allegation and did not see any bruises on C1's shoulders, but their investigation is still ongoing. LPA conducted a collateral visit to C1's Adult Day Program to interview C1 and C2. LPA attempted to interview C1 and C2, but C1 did not answer any questions because C1 was walking around the room and getting distracted and C2 was just repeating the LPA's questions and saying no. All 3 staff from the Adult Day Program stated to the LPA that C1 has frequently made statements that papa hit C1 or that papa pushed C1. They do not know who papa is. The ADP staff that is currently working closely with C1 stated that C1 says these statement whenever staff take a look at C1's self-injuries. C1 has a self-injury behavior which is documented in C1's file.

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: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

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