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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601373
Report Date: 03/30/2021
Date Signed: 04/01/2021 11:48:54 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/12/2019 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20190612103743
FACILITY NAME:JOMOK CARE HOMEFACILITY NUMBER:
015601373
ADMINISTRATOR:JOMOK, TERESITA N.FACILITY TYPE:
740
ADDRESS:999 TORRANO AVENUETELEPHONE:
(415) 250-1473
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY:12CENSUS: 9DATE:
03/30/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Teresita JomokTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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1. Resident sustained multiple pressure injuries while in care
2. Staff failed to seek medical attention in a timely manner
3. Staff restrained resident.
INVESTIGATION FINDINGS:
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On 3/30/2021, Licensing Program Analyst (LPA) Luisa Fontanilla conducted a televisit to deliver findings on the above allegations and met with Teresita Jomok. LPA explained to Administrator that the televisit via Facetime is being conducted in connection with the telework directive by management.

During the course of investigation, interviews were conducted and records including but not limited to R1's physician's report, Emergency Information, Preplacement appraisal, medical records and hospice care plan were reviewed. LPA conducted a physical tour of the facility on 6/14/2019.

1. Resident sustained multiple pressure injuries while in care
2. Staff failed to seek medical attention in a timely manner.
Based on the department's investigation, S1 was admitted to the facility without skin issues. Staff provided assistance with bathing, dressing and incontinent care for S1. After S1's doctor visit on 5/13/2019, the facility noticed "bruises" on S1. ****continuation on Lic9099C****
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020
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 6
Control Number 15-AS-20190612103743
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: JOMOK CARE HOME
FACILITY NUMBER: 015601373
VISIT DATE: 03/30/2021
NARRATIVE
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On 6/2/2019, the facility noticed the "bruises" were getting bad but R1 did not see a medical professional until 06/06/2019. On 06/06/2019, R1 had multiple unstageable pressure ulcers. Between 5/13/2019 and 6/6/2019, no medical attention was sought and there was no home healthcare provided.

3. Staff restrained resident.

On 6/20/2019, LPA interviewed Administrator in regards to the above allegation. Administrator states that R2 stayed at the facility for one day only. She added that she needed to move R2 out immediately because of his behavior. R2 was hitting the staff, banging walls and doors and disturbing other clients. Administrator admitted restraining R2 on the wheelchair to stop him from hitting the staff more.

Based on the Department and LPA observations, interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22 are being cited on the attached LIC 9099D.

A $500.00 immediate civil penalty is assessed on this day and $100.00 per day per day will continue until corrected. Civil penalty determination related to serious bodily injury is pending.

Exit interview conducted with Administrator and Appeal Rights was provided.

A copy of this report was provided to the Administrator via email.


SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20190612103743
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JOMOK CARE HOME
FACILITY NUMBER: 015601373
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/01/2021
Section Cited
CCR
87466
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 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs....... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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By POC date, Administrator states that:
1. inservice training on observation of residents will be conducted for staff
2. Administrator will read Sec 87466 and submit self-certification stating understanding of said regulation
3. staff will conduct daily skin check for
all residents and record in a log
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This requirement is not met as evidenced by:
Based on the Department and LPA investigations, the facility failed to monitor R1 for physical change which resulted to R1 developing multiple pressure injuries. R1 was admitted to the facility without skin issues as indicated in R1's medical assessment. As of 6/6/2019,R1 had multiple pressure injuries.
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 Proof will be sent to CCL by POC date.
Civil penalty of $500 is being assessed for less serious bodily injury.
Civil penalty determination related to serious bodily injury is pending.
Type A
04/01/2021
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. ........... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
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By POC date, Administrator states that:
1. in service training on Sec 87465(a)(1) will be conducted
2. Administrator will read Sec87465(a)(1) and submit self-certification of understanding
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Based on the Department's investigation, facility failed to seek medical attention between 5/13/2019 and 6/6/2019. R1 was admitted to the facility without skin issues. As of 6/6/2019, R1 had multiple pressure injuries.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/12/2019 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20190612103743

FACILITY NAME:JOMOK CARE HOMEFACILITY NUMBER:
015601373
ADMINISTRATOR:JOMOK, TERESITA N.FACILITY TYPE:
740
ADDRESS:999 TORRANO AVENUETELEPHONE:
(415) 250-1473
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY:12CENSUS: DATE:
03/30/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Teresita JomokTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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 Staff failed to notify the resident’s authorized representative of a change in medical condition.
2. Staff hit resident in care
3. Staff failed to keep resident's bed linens clean
4. Staff failed to keep the facility at a comfortable temperature
INVESTIGATION FINDINGS:
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On 6/14/19, LPA interviewed R1's daughter. On this day, LPA interviewed Administrator and 2 caregivers in connection with the above allegations.

1. Staff failed to notify the resident’s authorized representative of a change in medical condition.
Administrator provided LPA a copy of text messages between her and R1's daughter in regards to R1's wound on her legs, feet and side. However, R1's daughter states that staff did not notify her about R1's wound. She found out about them in one of her visits.
2. Staff hit resident in care
Administrator states R2 was at the facility for one day only. She needed to move him out because his behavior is not compatible with the other residents. R2 was hitting staff and banging doors and walls Administrator states that R2 was very aggressive towards staff but denied staff hitting R2. S1 and S2 both denied staff hitting R2.

*****continuation on Lic 9099 C*****
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
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 6
Control Number 15-AS-20190612103743
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: JOMOK CARE HOME
FACILITY NUMBER: 015601373
VISIT DATE: 03/30/2021
NARRATIVE
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3. Staff failed to keep resident's bed linens clean.
LPA checked facility's linen and observed there was sufficient supply for all the residents. Staff states that R1's daughter decided to bring R1's personal blanket, comforter and sheet. The rest of the linen were provided by the facility.

4. Staff failed to keep the facility at a comfortable temperature.
Administrator states that facility does not have an air conditioner. However, it has a fan system installed with vents to cool off the facility. There was a total of 7 additional fans observed in different resident rooms and common areas.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated..
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20190612103743
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JOMOK CARE HOME
FACILITY NUMBER: 015601373
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/02/2021
Section Cited
CCR
87468.1(a)(3)
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Personal Rights of Residents in All Facilities
a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living
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By POC date, Administrator will conduct staff training on Personal Rights and send proof to CCL
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functions such as eating, sleeping, or elimination.
This requirement is not met as evidenced by:
Based on interview with Administrator, R2 was hitting staff and other residents which led to staff restraining R2 in his wheelchair which poses a risk to resident's health and safety.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5