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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601373
Report Date: 02/15/2022
Date Signed: 02/15/2022 06:01:00 PM

Unsubstantiated


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 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
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Tess Cruz, Co-OwnerTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff handled resident in a rough manner
Staff verbally abuse residents
Facility has infestation of bugs
Facility failed to provide a safe and comfortable environment for residents in care
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.

Upon entrance, LPA toured the facility incuding but not limited to bedrooms, outdoor areas, bathrooms, a toilet paper, shampoo, hand soaps and toothpaste were observed. Residents said that they are happy and comfortable at the facility. Based upon records reviewed and interviews conducted the above allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Exit interview was conducted with Tess Cruz.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
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