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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197800633
Report Date: 08/18/2023
Date Signed: 08/18/2023 05:09:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/11/2023 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20230811104535
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:
08/18/2023
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Omar Sapalaran, assist administratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staffing schedule is inaccurate.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegation listed above today. During today’s visit, LPA met with Omar, assisted administrator. LPA explained the purpose of today's visit regarding the above-mentioned allegation.

Investigation consisted of the following: interviews of staff from staff #1 (S1) through staff #4 (S4); attempted to interview clients from client#1 (C1) to client#4 (C4); reviewed staff files and work schedules with timecards; and toured the facility. LPA obtained copies of staff and client rosters; and staff files with relevant information.

In regard to allegation of “facility staffing schedule is inaccurate,” it was alleged that staff’s approved work schedule did not match with facility’s time cards and hours paid to staff. The investigation revealed the following: LPA attempted to interview clients, all four (4) clients interviewed could not corroborate the allegation. Two (2) out of four (4) staff interviewed could not corroborate the allegation.
(-continued in LIC 9099C-)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
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 5
Control Number 28-AS-20230811104535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JOMAR RESIDENTIAL CARE CENTER
FACILITY NUMBER: 197800633
VISIT DATE: 08/18/2023
NARRATIVE
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Two (2) out of four (4) staff interviewed stated staff’s timecards did not match with staff’s work schedule. Staff interviews revealed that staff’s timecards had discrepancies with the hours worked at the facility. Per staff’s record review, there were discrepancies on staff payroll records from March 2023 to May 2023. Therefore, facility staffing schedule is inaccurate.

Based on LPA's observations, record reviews and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found SUBSTANTIATED.

Deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8 on LIC 9099D.

An exit interview was conducted with Omar, assisted administrator. A hard copy of this report and appeal right were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230811104535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 08/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2023
Section Cited
CCR
80066(f)
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Personnel Records (f) In all cases, personnel records shall document the hours actually worked.

This requirement was not met by evidence of:
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Licensee agreed to review Title 22 Regulations, Section 80066.(f) and submit a written plan detailing how administrator would ensure that personnel records on staff’s approved staffing work schedule would match with actual hours worked by POC due date.
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Staff’s approved work schedules did not match with hours actually work from March 2023 to May 2023.
Based on interviews and observation, the Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/11/2023 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20230811104535

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:
08/18/2023
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Omar Sapalaran, assist administratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility is storing expired milk.
Staff are preparing meals for residents with food that was removed from trash bins.
Facility is not meeting the dietary needs of a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tao conducted an unannounced complaint investigation for the allegation listed above today. During today’s visit, LPA met with Omar, assisted administrator. LPA explained the purpose of today's visit regarding the above-mentioned allegations.

Investigation consisted of the following: interviews of staff from staff #1 (S1) through staff #4 (S4); attempted to interview clients from client#1 (C1) to client#4 (C4); reviewed staff files; and toured the facility and kitchen. LPA obtained copies of staff and client rosters; and staff files with relevant information.

In regard to allegation of “facility is storing expired milk,” it was alleged that staff was instructed to take expired milk container and pour the milk into a different container with current date.

(-continued in LIC 9099 C-)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
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 5
Control Number 28-AS-20230811104535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JOMAR RESIDENTIAL CARE CENTER
FACILITY NUMBER: 197800633
VISIT DATE: 08/18/2023
NARRATIVE
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The investigation revealed the following: LPA attempted to interview clients, all four (4) clients interviewed could not corroborate the allegation. All four (4) staff interviewed denied the allegation. Staff interviews revealed that staff was not instructed and did not pour expired milk to different container. Per physical plant, LPA checked the food inventory on milk and it was current and looked fine. Therefore, facility is not storing expired milk.

In regard to allegation of “staff are preparing meals for residents with food that was removed from trash bins,” it was alleged that facility staff re-collected the canned foods from trash and took them back to cook to clients. The investigation revealed the following: LPA attempted to interview clients, all four (4) clients interviewed could not corroborate the allegation. All four (4) staff interviewed denied the allegation. Staff interviews revealed staff did not take the canned food from trash and cook to serve clients. During the visit, LPA toured the kitchen, checked canned food, found none expired and did not see any canned food in trash can being taken back to cook. Therefore, facility did not have prepare meals to clients with food from trash bins.

In regard to allegation of “facility is not meeting the dietary needs of a resident in care,” it was alleged that no diabetic snacks available for diabetic client. The investigation revealed the following: LPA attempted to interview clients, all four (4) clients interviewed could not corroborate the allegation. All four (4) staff interviewed denied the allegation. Staff interview revealed that snacks for diabetic clients were available and being given to diabetic client. During the visit, LPA checked food supply and observed low sugar snack packs, string cheese and sugar free puddings/jello were in stock. Therefore, facility had provided snacks to client for client’s dietary needs.

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 allegations are UNSUBSTANTIATED.

No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted with Omar, assisted administrator. A hard copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5