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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197800633
Report Date: 06/08/2023
Date Signed: 06/08/2023 02:41:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230601100208
FACILITY NAME:JOMAR RESIDENTIAL CARE CENTERFACILITY NUMBER:
197800633
ADMINISTRATOR:JOSEPHINE SAPALARANFACILITY TYPE:
735
ADDRESS:3920 N FRIJO AVETELEPHONE:
(626) 338-4551
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:4CENSUS: 4DATE:
06/08/2023
UNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Omar Sapalaran – AdministratorTIME COMPLETED:
02:56 PM
ALLEGATION(S):
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Facility staff serve expired foods.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegation. LPA met with Omar Sapalaran (Administrator) and explained the reason for the visit.

The investigation consisted of the following: LPA Mora toured the facility's kitchen and obtained a copy of staff schedule. LPA interviewed the Administrator, Staff 1 (S1) via phone, Staff 2 - 4 (S2 - S4) , Client 1 - Client 4 (C1 - C4), and Regional Center Representative.

The investigation revealed the following: regarding the allegation "facility staff serve expired foods”, it is alleged that the facility serves the clients expired foods received from the food bank and leftover food from restaurants.
(Continued to LIC 9099-C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
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 6
Control Number 28-AS-20230601100208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JOMAR RESIDENTIAL CARE CENTER
FACILITY NUMBER: 197800633
VISIT DATE: 06/08/2023
NARRATIVE
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Staff interviewed denied the allegation. Clients interviewed could not corroborate the allegation. During the tour of the kitchen, the LPA observed a salad dressing that expired on 02/02/2022, frozen unopened turkey breast packaged on 01/25/2021, and unopened frozen beef that had a best by date of 09/13/2021. Interviewed with Regional Center Representative revealed that they did an unannounced visit on Sunday (06/04/2023) and found a can of tuna, green beans, tomato sauce, and peas that were expired or had no expiration dates on them.

Based on LPA's interviews, records reviewed and observations, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 6 are being cited on the attached LIC 9099-D.

Exit interview held and a copy of the report and appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20230601100208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JOMAR RESIDENTIAL CARE CENTER
FACILITY NUMBER: 197800633
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2023
Section Cited
CCR
80076(a)(1)
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(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients....

The requirement was not met as evidenced by:
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Facility is to ensure that Title 22 Section 80076 regulations are met at all times. Additionally, facility will inspect all foods and tossed expired foods by 06/09/2023. Facility will also provide training to all staff regarding this regulation and submit training log with staff signatures to CCLD by 06/15/2023.
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA found expired salad dressing & bottle of sauce, and frozen meats with packaged by 01/25/2021 & best by 09/13/2021 dates.
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***Administrator removed and tossed away expired foods and frozen foods over a year during the visit***
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/01/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230601100208

FACILITY NAME:JOMAR RESIDENTIAL CARE CENTERFACILITY NUMBER:
197800633
ADMINISTRATOR:JOSEPHINE SAPALARANFACILITY TYPE:
735
ADDRESS:3920 N FRIJO AVETELEPHONE:
(626) 338-4551
CITY:COVINASTATE: CAZIP CODE:
91722
CAPACITY:4CENSUS: 4DATE:
06/08/2023
UNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Omar Sapalaran – AdministratorTIME COMPLETED:
02:56 PM
ALLEGATION(S):
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Facility is operating out of ratio.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegation. LPA met with Omar Sapalaran (Administrator) and explained the reason for the visit.

The investigation consisted of the following: LPA Mora toured the facility's kitchen and obtained a copy of staff schedule. LPA interviewed the Administrator, Staff 1 (S1) via phone, Staff 2 - 4 (S2 - S4) , Client 1 - Client 4 (C1 - C4), and Regional Center Representative.

The investigation revealed the following: regarding the allegation "facility is operating out of ratio”, it is alleged that there should be 2 staff on every shift, but there is only 1 staff scheduled for four clients.

(Continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20230601100208
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JOMAR RESIDENTIAL CARE CENTER
FACILITY NUMBER: 197800633
VISIT DATE: 06/08/2023
NARRATIVE
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Staff interviewed denied the allegation and stated there is always 2 staff per shift. Administrator stated that 1 of the clients requires one on one, therefore, they have 1 staff for this client and 1 staff for the other 3 clients. Clients interviewed could not corroborate the allegation. Interviewed with Regional Center Representative revealed that there should be 2 staff per shift and that the ration is 1 staff per 3 clients. Regional center did not observe any staffing issues on their last unannounced visit on Sunday (06/04/2023). Review of the facility's staff schedule the LPA observed that there are 2 staff schedule per shift. During this visit, the LPA observed 2 staff at the facility.

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

Exit interview conducted, and a copy of report and appeal right was provided to Administrator Omar Sapalaran.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6