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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601373
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:47:25 PM


Document Has Been Signed on 04/21/2022 04:47 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: 9DATE:
04/21/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Juliet Pacaldo, NurseTIME COMPLETED:
05:05 PM
NARRATIVE
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On 4/21/22 at 1-20 PM, Licensing Program Analysts (LPAs) C. Lin and L. Fici conducted case management while conducting Pre-licensing Required inspection for changing of ownership. LPAs met with nurse Juliet Pacaldo and explained the purpose of the visit.


THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • Laundry detergent and cleaning supplies were observed unlocked in the laundry room.
  • Medication was observed unlocked in two residents' room and kitchen.
  • Knives and scissor were observed unlocked in the kitchen.


The above 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 with Administrator. LIC809D, Appeal Rights and a copy of this report provide.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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 2


Document Has Been Signed on 04/21/2022 04:47 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: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2022
Section Cited

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)
This requirement is not met as evidenced by…
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Based on observation, the licensee did not comply with the section cited above. LPAs observed unlocked knives and scissor in the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.

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Type A
04/22/2022
Section Cited

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87705 Care of Persons with Dementia
(f) 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.
This requirement is not met as evidenced by…
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Based on observation, the licensee did not comply with the section cited above. LPAs observed unlocked medications and cleaning supplies, which poses an immediate health, safety or personal rights risk to persons in care.
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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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2