015601373-10-12-2022-15-AS-HHUL-CKMLHJ-20221028084626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601373
Report Date: 10/12/2022
Date Signed: 10/12/2022 05:29:46 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
08/04/2022 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20220804134400

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:	0	CENSUS: 10	DATE:	10/12/2022
		UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Mary Joy Pacalo, Administrative assistant for Pacaldo-Yee		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Resident had to be hospitalized due to staff negelct while in care

INVESTIGATION FINDINGS:

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On 10/12/2022, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPA met with S3, and explained the reason for the visit. Adminsitrator was not avaialable during LPA's visit. LPA spoke with new facility owner Juliet Pacaldo via phone and explained her the purpose of the visit.

During the course of the investigation, the Department conducted interviews with staff, residents and health providers. R1’s medical records and facility file, incident report, and facility’s correspondence with health providers were obtained and reviewed.

REPORT CONTINUES ON 9099C

Unsubstantiated

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: 10/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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-20220804134400

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
	VISIT DATE: 10/12/2022

NARRATIVE

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The Department investigated allegation Resident had to be hospitalized due to staff neglect while in care. Based on information obtained, R1 was admitted at the facility on 12/14/2021, during the admission it was reported that R1 had skin tear/abrasion on her left thigh fold. Home health was ordered.

On 12/16/2021 home health had concerned due the facility’s insufficient resources for repositioning due to R1’s severe obesity and needed higher level of care such as additional staff. The licensee provided additional staff and R1’s family member was also assisting her with other Activity of Daily living ( ADL ).

Based on home health notes, R1 denied any kind of physical abuse, verbal abuse or neglect from the facility staff. On 12/23/2021 R1 reported that the facility improved care by facility staff. On 1/6/2022 R1 stated that facility hired additional staff to assist her on her ADL’s.

Based on interview with staff, R1 wanted to go home on the day they admitted her at the facility, however her home is still under construction, so she had to stay at the facility. On 1/12/2022 R1 initiated to be discharge at her own to home. On March 3, 2022 R1 gave verbal notice of discharge to new facility owner Juliet Pacaldo, on March 7, 2022 R1 left the facility.

Based on interview with staff they were surprised when F1 picked up R1 from the facility via u-haul van and told the staff that R1 is moving out from the facility. Paramedics was called to assist staff on transferring R1 from her bedroom to the u-haul van.

Based on records review, on 3/17/2022, R1 had doctor’s visit via video, based on the report R1 was on her “baseline”, R1 stated she no longer live at the facility. Based on the report, there were no ulcers on her legs or under her breast as it was reported from the facility.

This agency has investigated the complaint. Although the allegation may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with S3 and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC9099 (FAS) - (06/04)

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