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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
015601373
Report Date:
10/12/2021
Date Signed:
10/12/2021 12:12:39 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 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:
12
CENSUS:
11
DATE:
10/12/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:25 AM
MET WITH:
Juliet Pacaldo
TIME COMPLETED:
12:30 PM
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On 10/12/2021 Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct case management visit in connection with SOC341 received on 9/29/2021. LPA met with transitioning Administrator Juliet Pacaldo. There were 11 residents and 3 caregivers observed.
LPA conducted interview and records review. Information gathered and documented on LIC812. R1 passed away at the hospital on 10/2/2021.
No deficiency cited during this visit.
Exit interview conducted a copy of this report provided to transitioning Administrator Juliet Pacaldo.
SUPERVISOR'S NAME:
Harpreet Humpal
TELEPHONE:
(510) 285-3928
LICENSING EVALUATOR NAME:
Leslie Ibo
TELEPHONE:
510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/12/2021
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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