<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601373
Report Date: 03/04/2022
Date Signed: 03/04/2022 01:05:18 PM


Document Has Been Signed on 03/04/2022 01:05 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: 10DATE:
03/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Juliet Pacaldo, staff/applicant for new license & Tess Cruz Co-ownerTIME COMPLETED:
01:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 3/4/2022, Licensing Program Analyst (LPA) L.Ibo arrived unannounced to conduct a case management visit due to incident report received on 3/2/2022. LPA met with Juliet Pacaldo and Tess Cruz

LPA interviewed S1, according to S1, on 3/1/2022 staff called ambulance for R1 because of weeping wound, R1 refused, staff explained to R1 risk and consequences of not going to the hospital, R1 still refused, on the same day staff called advise nurse for R1 to get advice regarding R1’s condition. On 3/4/2022 S1 called ambulance for R1, resident refused to go to the hospital.

No citation noted during the visit.

Exit interview conducted and a copy of this report provided
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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 1