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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610312
Report Date: 10/06/2024
Date Signed: 10/06/2024 03:51:54 PM

Document Has Been Signed on 10/06/2024 03:51 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:JW CARE HOME, LLCFACILITY NUMBER:
197610312
ADMINISTRATOR/
DIRECTOR:		SALAMERO, JOJOMAURELI B.FACILITY TYPE:
740
ADDRESS:37944 MOONDANCE DRIVETELEPHONE:
(661) 285-3255
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 5CENSUS: 4DATE:
10/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:51 PM
MET WITH:Jojomaureli Salamero - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Gary Tan conducted a One Year Required visit at this facility today and met with the Administrator Jojomaureli Salamero. LPA informed the administrator the purpose of the visit.

At 1:03 PM, A tour of the physical plant was conducted with Ms. Salamero. The facility has five (5) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) bedroom is designated for staff use. The facility fire cleared for five (5) non-ambulatory residents, one of which maybe bedridden.

Infection control: The facility has submitted and approved Mitigation Plan and Infection Control plan on file. The main door is the only entrance being utilized at the facility. Screening area is located in immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. Hand washing sign are posted on the bathroom. The facility has an approved Infection Control and Mitigation Plan.

Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted:

Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 75°F. The smoke detectors and alarms are interconnected and hardwired and observed to be fully operational. There is a carbon monoxide installed and observed to be operational. The door alarms were also and observed to be operational. The fire extinguisher is located at the dining room and observed to be full and current.

The front of the facility has outdoor furniture and the backyard has shaded area. There is no body of water at the facility. The garage was observed to be locked and inaccessible to residents and also being used as Laundry area, storage for frozen food, PPE, other supplies, laundry detergent, cleaning agents and other toxins. The backyard has a locked tool she being used as old equipment storage. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: JW CARE HOME, LLC
FACILITY NUMBER: 197610312
VISIT DATE: 10/06/2024
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(continued from LIC 809)

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, pesticides, detergents and/or toxins are stored in the cabinet below the kitchen sink and were locked and inaccessible to residents. Knives and sharps are also locked in a kitchen drawer.
The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are appropriately lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.
Staff Rooms: Staff room was locked. No medication was observed in the staff room.
The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 109.3°F to 111.2°F . Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.
Medications: LPA observed the medication in the bedroom hallway cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. The first aid kit was complete and stored in the medication cabinet.
Client records: All client records wee reviewed. Client records appeared to be complete and updated.
Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated.

Disaster drill was last conducted on 09/08/24. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2024
LIC809 (FAS) - (06/04)
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