015601373-2-15-2022-15-AS-KHOS-CKBNQ8-20221018103930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601373
Report Date: 02/15/2022
Date Signed: 02/15/2022 06:00:39 PM

Substantiated

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
02/08/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220208142058

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: 12	DATE:	02/15/2022
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Tess Cruz, Co-owner		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility is dirty and unkempt

INVESTIGATION FINDINGS:

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On 02/15/2022 at 10:10AM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to in order to meet the 10-day requirement for notification of the above allegation. LPA met with Tess Cruz, Co-owner of the facility, LPA called Administrator Juliet Pacaldo, Administrator is not available during the visit. LPA explained the purpose of the visit to Tess Cruz.

LPA toured the facility with S2, LPA observed fruits and vegetables on top of a table at the patio area of the facility, the fruits and vegetables are observed to have molds on it.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.

Substantiated

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220208142058

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/25/2022 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.	1 2 3 4 5 6 7	S2 cleaned up throw the old frutis and vegetables.
	8 9 10 11 12 13 14	Based on the observation and interview, the licensee failed to ensure that the facility is clean, LPA observed molded fruits and vegetable lying around the patio table that is accesible to residents in care which poses a potential health and safety risks to clients in care.	8 9 10 11 12 13 14	Licensee agreed with LPA to train the staff regarding the cited regulation,proof of training and a copy of training topics, staff names and signatures need to be submitted to CCL office by POC date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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