079200976-7-29-2026-15-AS-BFOG-DWVSCR-20260812134558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200976
Report Date: 07/29/2026
Date Signed: 07/29/2026 11:40:00 AM

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
06/01/2026 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20260601101218

FACILITY NAME:	JANGA CARE HOME		FACILITY NUMBER:	079200976
ADMINISTRATOR:	KOLLIE, COMFORT K.		FACILITY TYPE:	740
ADDRESS:	3601 GENTRYTOWN DR		TELEPHONE:	(510) 677-3734
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY:	6	CENSUS: 4	DATE:	07/29/2026
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Kumba Quermollu/Staff Comfort Kollie, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff neglect/lack of care and supervision of resident

INVESTIGATION FINDINGS:

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On 07/29/26 at 10:45 AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit, met with staff (S1) and spoke to administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the repots. LPA gathered information and delivered investigation findings to staff (S1,ADM). LPA explained the purpose of the visit with staff.

On 06/02/26 and 06/08/26, LPA D Panlilio conducted interviews with reporting party (RP), responsible party (POA), staff (ADM, S1) and obtained the following documents: Personnel record (LIC500), Residents roster, R1's admission agreement, pre-placement appraisal, needs & services plan, physician's report, ID/Emergency information, staff notes, centrally stored medication logs, medication administration records and incident reports.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026

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-20260601101218

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: JANGA CARE HOME	FACILITY NUMBER: 079200976
	VISIT DATE: 07/29/2026

NARRATIVE

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Allegation: Facility staff neglect/lack of care and supervision of resident
Investigation Finding: Unsubstantiated
During investigation, LPA D Panlilio conducted interviews with reporting party (RP), responsible party (POA), facility staff (ADM, S1) and reviewed resident (R1) documents. R1 was first admitted at the facility on 10/13/23. Review of R1’s functional assessment dated 10/28/24 showed him as ambulatory - able to move in and out of bed or chair, feeds himself completely, sits without support, has no vision problem or hearing loss, uses a walker to ambulate, able to use the restroom and empty his Foley bag independently. Review of R1’s physician’s report dated 09/27/23 showed there was no history of R1 being a high fall risk.

On 05/29/26, staff noticed a change in condition in R1 (limping and complaining of left flank pain) and sent him to the hospital for treatment and evaluation. ER doctor diagnosed him with a left fractured hip due to a possible fall. LPA interviewed staff (ADM, S1) who stated they did not witness R1 fall while in care at the facility. LPA interviewed POA who stated that R1 may have had an unwitnessed fall during the night at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation of facility staff neglect, lack of care and supervision of resident is unsubstantiated.

No deficiency cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2026

LIC9099 (FAS) - (06/04)

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