015601373-5-2-2023-15-AS-KHOS-CRLQJS-20230507121312

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601373
Report Date: 05/02/2023
Date Signed: 05/02/2023 12:12:15 PM

Unsubstantiated

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
02/28/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220228142059

FACILITY NAME:	JOMOK CARE HOME		FACILITY NUMBER:	015601373
ADMINISTRATOR:	JOMOK, TERESITA N.		FACILITY TYPE:	740
ADDRESS:	999 TORRANO AVENUE		TELEPHONE:	(415) 250-1473
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94542
CAPACITY:	0	CENSUS: 10	DATE:	05/02/2023
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Kester Orandin, staff on duty		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff is mishandling residents in care
Residents are not provided dignity and respect
Residents not being provided adequate food service
Staff is stealing from residents.
Residents not being provided adequate service.

INVESTIGATION FINDINGS:

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On 5/2/2023 at around 9:30 AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver findings for the above allegations. LPA met staff Kester Orandin, LPA informed her the purpose of the visit. LPA spoke with co-owner of the new license, Tess Cruz and informed her the purpose of the visit. Tess gave permission to LPA to have the staff sign for the report and provide a copy of the report to staff Kester Orandin.

During the course of investigation, LPA conducted records review and staff and residents’ interview. Based on records review there was no incident report regarding clients/residents being handled in rough manner, the facility does not have incident report of any type of clients/residents bruising from an inappropriate handling of residents in care. Based on staff interview, they are not aware of any staff handling anyone roughly.

CONTINUE TO LIC9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

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 15-AS-20220228142059

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: 05/02/2023

NARRATIVE

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Staff denied witnessing or heard any staff acting inappropriate behavior towards residents in care and staff denied observing any staff yelling at the residents in care.

Based on interview with residents and staff, they denied witnessing or experienced an incident staff stealing money from residents in care.

Based on interview with staff and residents, the staff are taking care of the residents and provides care that residents need. Based on residents’ interview, the residents are comfortable living at the facility.

Based on staff and residents’ interview, the facility provides three meals a day and snacks in between. Residents stated that the facility provides adequate food to residents in care.

Based on LPA’s observation, residents appeared to be wearing clean clothing, facility is clean and sanitary. LPA observed adequate food supplies, during LPA’s visit on 5/2/2023, LPA observed lunch being served to residents in care.

Based upon the information obtained during investigation. The above allegation are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conduct and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

LIC9099 (FAS) - (06/04)

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