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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601373
Report Date: 02/15/2022
Date Signed: 02/15/2022 06:09:08 PM


Document Has Been Signed on 02/15/2022 06:09 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
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: 12DATE:
02/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Tess Cruz, co-owner of the facilityTIME COMPLETED:
06:40 PM
NARRATIVE
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While conducting another inspection visit, Licensing Program Analyst (LPA) Leslie Ibo
conducted a Case Management and met with Co-owner Tess Cruz.

During LPA's facility tour the following was observed:

S2 do not have fingerprint clearance.
Lysol disinfectant spray accessible to residents in care. Corrected during the visit.
1 bedridden resident reside at the facility and facility do not have bedridden resident.


The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

A civil penalty is being assessed today.

Exit interview conducted. Appeal Rights and a copy of this report was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
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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Document Has Been Signed on 02/15/2022 06:09 PM - It Cannot Be Edited

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: 02/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2022
Section Cited

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87355(e)(1) Criminal Record Clearance
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working..Obtain a California clearance..

This requirement was not met as evidenced by:
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Based on LPA's observation and interview, Licensee failed to obtain criminal record clearance for S2 which poses an immediate health and safety risk to residents in care.
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Type A
02/15/2022
Section Cited

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Care of Persons with Dementia The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants
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This requirement is not met as evidenced by:
LPA observed facility failed to lock Lysol sprays which is an immediate risk to client's health and safety.
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LPA requested from Licensee to train all staff regarding the regulation that was cited, a proof of training with staff names and signature is required to send to CCL office on or before 02/25/2022.
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: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/15/2022 06:09 PM - It Cannot Be Edited

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: 02/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2022
Section Cited

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87202 Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons...(2) Bedridden persons

This requirement is not met as evidence by:
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Based on observation and interviews, Licensee failed to obtain fire clearance for bedridden resident. LPA observed R3 is bedridden. However, facility does not have bedridden clearance which poses an immediate health and safety risk to residents in care.
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A civil penalty of $500.00, is being assessed today.

Submit updated LIC602A.

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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: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3