015601373-1-21-2023-15-AS-KHOS-CNDMLN-20230124084238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601373
Report Date: 01/17/2023
Date Signed: 01/21/2023 07:01:01 AM

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
06/29/2021 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210629120656

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: 0	DATE:	01/17/2023
		ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Teresita Jomok, Licensee/Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility not clean.

INVESTIGATION FINDINGS:

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On 1/17/2023 at 1:00PM, Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit via FaceTime to deliver findings in regards to the allegation above. LPA spoke with Licensee/Administrator, Teresita Jomok.

During the course of investigation, LPA interviewed resident and 3 staff. LPA obtained and reviewed documents including resident roster, admission agreement, emergency information, resident appraisal, staff schedule for November 2020, and Terminix contract plan. On 7/7/2021, LPA observed facility bathrooms were unclean and there were cobwebs around the facility.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is 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: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 15-AS-20210629120656

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: 01/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/18/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidence by:	1 2 3 4 5 6 7	No plan of correction at this time. Facility had a change of ownership and has been closed.
	8 9 10 11 12 13 14	Based on investigation, licensee did not comply with the section cited above by having uncleaned bathrooms and cobwebs around the facility which poses a potential health and safety risk to the persons in care.	8 9 10 11 12 13 14
	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: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
06/29/2021 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210629120656

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: 0	DATE:	01/17/2023
		ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Teresita Jomok, Licensee/Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Lack of adequate supervision resulted in resident falling out of bed.
Staff did not provide timely service/help.
Facility is disrepair.
Facility has vermin.

INVESTIGATION FINDINGS:

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On 1/17/2023 at 1:00PM, Licensing Program Analyst (LPA) G. Luk conducted a Tele-visit via FaceTime to deliver findings in regards to the allegations above. LPA spoke with Licensee/Administrator, Teresita Jomok.

During the course of investigation, LPA interviewed resident and 3 staff. LPA obtained and reviewed documents including resident roster, admission agreement, emergency information, resident appraisal, staff schedule for November 2020, and Terminix contract plan.

Lack of adequate supervision resulted in resident falling out of bed.
Interview with staff revealed that R1 does not require 1:1 care and supervision. Staff stated that R1 slide out of bed once and staff helped R1 back to bed. Record review show that appraisal was incomplete.
(Continue on LIC9099...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20210629120656

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: 01/17/2023

NARRATIVE

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Staff did not provide timely service/help.
Interview with resident indicated it took 10 minutes after a fall for staff to assist resident back to bed. Staff stated that caregiver's rooms were close by and responded in 5 minutes after R1 fell out of bed to assist R1 back to bed.

Facility is disrepair.
Interview with staff and resident revealed electricity have gone out before. However, staff was able to turn the power back on and facility was not without power for a long period time.

Facility has vermin.
Interview with staff revealed that facility had bug issues in the past due to one resident who was a hoarder. After Terminix was called, there was no issues. Terminix contract dated 2/26/2021 showed that services were conducted every other month including February, April, June, August, October, and December of 2021.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4