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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603104
Report Date: 08/17/2022
Date Signed: 08/17/2022 04:25:43 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
07/20/2022 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220720150348
FACILITY NAME:TOMINES ADULT RESIDENTIAL FACILITY IFACILITY NUMBER:
198603104
ADMINISTRATOR:TOMINES, JONATHANFACILITY TYPE:
735
ADDRESS:6234 N BURTON AVETELEPHONE:
(626) 848-8836
CITY:SAN GABRIELSTATE: CAZIP CODE:
91775
CAPACITY:4CENSUS: 3DATE:
08/17/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jasmin Tomines, Assistant AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility does not follow Regional Center's staff ratio.
Facility failed to report staff COVID cases.
Licensee failed to obtain criminal record clearance for staff.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Galarza & Baptiste conducted a subsequent complaint visit regarding the above allegations and delivered findings. The purpose of the visit was discussed with staff Rosauro "Jun" Tecson. Assistant Administrator Jasmin Tomines arrived later.

The investigation consisted of: On 7/28/2022, Eastern Los Angeles Regional Center Community Services Specialist Arturo Castellanos joined LPA during the initial 10-day complaint visit. Staff (S1- S5) and client (C1) were interviewed. Clients (C2 & C3) are non-verbal and were not interviewed. Staff (S6 & S7) were not available for interviews. A physical plant tour of the facility was conducted. LPA reviewed and obtained the following documents: [Face Sheet/ID & Emergency Information, Individual Program Plan (IPP), Behavior Plan, Physician's Report, staff schedules for months June 2022- July 2022, incident report dated 7/19/2022] was completed. During today's visit, LPAs toured the facility and asked staff present to sign LIC855 Declaration forms.

See LIC 9099C for report continuation.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
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-20220720150348
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: TOMINES ADULT RESIDENTIAL FACILITY I
FACILITY NUMBER: 198603104
VISIT DATE: 08/17/2022
NARRATIVE
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Allegation: "Facility does not follow Regional Center's staff ratio." It is alleged that the facility only has two (2) permanent staff working at the facility, and when there are staffing shortages, the licensee brings staff from his other facility "Tomines Adult Residential Facility II" located in Montebello. Per, Eastern Los Angeles Regional Center client (C1) requires 1 to 1 staff care. Client (C1) was visiting overnight at it's mother's home and required medical care. Client (C1) was hospitalized on 7/19/2022. The Eastern Los Angeles Regional Center (ELARC) gave the facility an exception that allowed C1's 1 to 1 caregiver (S1) to work from C1's mother's home. Staff (S1) worked at C1’s mother’s home from July 13, 2022 – July 19, 2022. The Regional Center provided the facility an exception for S1 to work from C1's mother's home because the client is medically fragile.

All staff interviewed denied the allegation and stated that there is always sufficient staffing to meet the client’s needs. However, per document review of facility staff schedules (June 2022- July 2022) the findings indicate the facility has had primarily two (2) staff working 16+ hours. It is noted that staff (S5) has worked +20 hours per day 7 times from June 2022- July 2022. Staff (S5) acknowledged that it has worked long hours due to staffing shortages. Per approved program design/Plan of Operation the facility shall have three (3) different shifts [Morning, Afternoon, Overnight] and "staff to work 10 to 12 hours in a given day." The staff schedules furnished showed the facility violated the Staffing Plan and Hours because staff on duty were working more than 12 hours per shift.

Allegation: "Facility failed to report staff COVID cases." Based on record review the findings indicate that Licensee/Administrator deliberately neglected to report that DSP staff (S1) and DSP staff (S6) tested positive for COVID-19. On 7/15/2022, Administrator Jonathan Tomines faxed two client incident reports reporting 2 new COVID-19 client cases. On 7/19/2022, a third client incident report was faxed reporting another COVID-19 cases; totaling three (3) COVID-19 positive clients. Administrator failed to report that DSP staff (S6) tested positive on 7/14/2022, and that DSP staff (S1) tested positive on 7/15/2022. Staff (S1) confirmed it tested positive for COVID-19. Staff (S6) was not interviewed because it is not working at this facility at this time. However, staff (S6) works at another facility that did report staff (S6) tested positive. Licensee/Administrator is aware and is expected to report all staff COVID-19 cases to Community Care Licensing and LA County Department of Public Health. Staff stated they were not aware that staff (S6) tested positive, and did not know they had to report that staff (S1) tested positive during the exception work assignment approved by the Regional Center. As of today, CCL has not received the incident reports regarding the staff COVID-19 positive cases related to S1 and S6.
See LIC 9099C for report continuation.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20220720150348
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: TOMINES ADULT RESIDENTIAL FACILITY I
FACILITY NUMBER: 198603104
VISIT DATE: 08/17/2022
NARRATIVE
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Allegation: "Licensee failed to obtain criminal record clearance for staff." It is alleged that staff (S7) has been working the overnight shift without being fingerprint cleared. Staff (S7) is staff (S1's) husband. Per record review, two DSP staff that worked the night shift stopped working in July 2022, and staff (S7) began working at the facility during the night shift when needed. Staff (S7) was not interviewed. Administrator Jonathan Tomines stated that S7 attempted to work at the facility but did not get fingerprint clearance. Administrator denied that S7 is staff floater. One (1) client confirmed that S7 is a new staff person that works during the night shift. A third party was interviewed and stated that S7 works overnight on-call as a back-up staff when needed. Assistant Administrator stated that staff (S7) did not work at the facility, and would only visit the facility.

Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22. See LIC 9099D.

An exit interview was conducted with Assistant Administrator Jasmin Tomines. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220720150348
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: TOMINES ADULT RESIDENTIAL FACILITY I
FACILITY NUMBER: 198603104
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2022
Section Cited
CCR
80022(k)
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Plan of Operation. The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so.

This requirement is not met evidenced by:
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Licensee/Administrator agreed to:
1. Adhere to approved Plan of Operation Staffing Plan and Hours.
2. Hire additional staff if needed.
Submit a written plan regarding staffing schedules, and a copy of staff in-service training.
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Based on record review and interviews conducted two staff [S1 & S5] have worked more than 12 hours per shift. During June 2022- July 2022 staff (S5) worked 20+ hours a total of 7 times. The Plan of Operation states "staff to work 10 to 12 hours in a given day." This poses a potential health and safety risk to residents in care.
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CCR
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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.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220720150348
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: TOMINES ADULT RESIDENTIAL FACILITY I
FACILITY NUMBER: 198603104
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2022
Section Cited
CCR
80061(1)(H)
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Reporting Requirements. A report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report ...shall be submitted to the licensing agency within seven days following the occurrence of such event. Epidemic outbreaks. This requirement is not met evidenced by:
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Licensee/Administrator shall fax an incident report to CCL and report to LA County Department of Public Health the 2 staff cases not previously reported.

Submit proof of staff in-service training regarding reporting requirements.
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Based on interviews conducted and record review the facility deliberately neglected to report to CCL that S1 tested positive for COVID-19 on 7/15/2022 & S6 tested positive for COVID-19 on 7/14/2022. This poses an immediate health and safety risk to residents in care.
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Type A
08/18/2022
Section Cited
CCR
80019(d)
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Criminal Record Clearance. All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not met as evidenced by:
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Licensee/Administrator was informed that staff (S7) will not be allowed to work until the fingerprint clearance has been processed.

Submit certification that all staff will be fingerprinted and associated to the facility prior to beginning employment.
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Based on interviews conducted, the licensee did not comply with the section cited above in that staff (S7) has been observed working during the night shift and does not have fingerprint clearance; which poses an immediate 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.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5