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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601373
Report Date: 07/07/2021
Date Signed: 07/07/2021 12:48:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Teresita Jomok, AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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On 7/7/2021 at 8:45AM, Licensing Program Analyst (LPA) G. Luk and Staff Services Analyst (SSA) S. Vincent arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Teresita Jomok and explained the purpose of the visit.

Upon entry, LPA and SSA temperatures were checked, and hand sanitizer was observed at screening station. LPA and SSA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area, and outdoor area. Cough etiquette, physical distancing, and signs & symptoms were posted in the common areas.

During record review, visitors log was observed. LPA observed facility has a copy of Mitigation Plan on file. Food supplies were sufficient.

The following deficiencies were observed during the visit:
-At 9:00AM, unlocked medications were observed in the kitchen. The door to the kitchen was unlocked during visit.
-At 9:30AM, unlocked hammer in the patio area. Staff locked up hammer during inspection.
-At 10:00AM, facility did not keep documentation of resident's observation notes.
-At 10:20AM, LPA and SSA observed administrator did not have knowledge regarding CCLD regulations/PINs. Facility have not been documenting staff/resident temperature screening, have no records of staff COVID-19 surveillance testing, some CCLD postings (hand washing) are not found in common areas, no liquid soap & paper towels in bathroom, no gowns observed, and facility does not have a 30 day supply of PPEs.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having an unlocked hammer in the patio area which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/08/2021
Plan of Correction
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Staff removed and locked up the hammer during inspection.

Deficiency cleared during inspection.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked medication which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/08/2021
Plan of Correction
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Administrator has agreed to conduct an in-service training to lock the kitchen door where the medications were kept at all times. Administrator will submit staff sign-in sheet by POC date.
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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not documenting resident observation which poses a potential health and safety risk to persons in care.
POC Due Date: 07/12/2021
Plan of Correction
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Administrator will conduct training for staff on documenting resident observation regularly and submit self-certification to CCLD by POC date.
Type B
Section Cited
CCR
87405(d)(2)
Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by not having knowledge of CCLD COVID-19 guidelines/regulations which poses a potential health and safety risk to persons in care.
POC Due Date: 07/12/2021
Plan of Correction
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Adminstrator has agreed to review current CCLD guidelines/PINs and submit self-certification to CCLD by POC date.
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: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021
LIC809 (FAS) - (06/04)
Page: 3 of 7