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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 03:40:40 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
08/01/2022 and conducted by Evaluator Jewel Baptiste
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220801140638
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:
04:00 PM
ALLEGATION(S):
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Administrator is not allowing resident to have visit
INVESTIGATION FINDINGS:
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***This complaint report was reissued due to incorrect findings issued on 8/9/2022. Additional information was obtained, and the allegation will be substantiated. An LIC 9099D will be issued today. This report will supersede all other reports and citations****

On 8/17/22 Licensing Program Analyst(s) (LPAs) Jewel Baptiste and Noemi Galarza conducted a subsequent complaint visit to Tomine’s Adult residential homes, met with Assistant Administrator, Jasmine Tomines. The purpose of the visit was to reissue report and update the findings on the above allegation.

The investigation consisted of the following: On 8/9/2022 LPA toured the facility, obtained the resident/ staff roster, and obtained a copy of the house rules, visitor log, plan of operation and visiting schedule for C1. LPA interviewed assistant Administrator, S1, S2 and S3. LPA interviewed C2 a1 and C1 is nonverbal.

Report continued on 9099C
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST 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 3
Control Number 28-AS-20220801140638
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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The investigation reveals the following: In regard to “Administrator is not allowing resident to have visit”. The details of this allegation state that the facility is not allowing visitations without appointments. LPA observed a family member visiting a client while conducting the investigation. House rules stated families can visit any time and they can visit during planned activities if visitors do not infringe upon the rights of other clients. LPA confirmed page 61 of the plan of operation stated, “Clients may have visitors at the facility at any time”. File review for C1 confirmed there is no restraining order on file. LPA also observed visitation logs for the last 5 months and confirmed that all clients are receiving visitations, but C1 family member has set appointments. C1 family member confirmed schedule visitations is an issue due to aging and transportation. C1 family member was placed on a visitation schedule, only Tuesdays and Fridays from 10/10:30 am - 1/1:30 pm. The Facility issued a visitation schedule to C1 family member, that was signed by all staff, C1’s family member and assistant administrator. Assistant administrator confirmed set appointments for C1 family member. 3/3 staff confirmed C1 family has set appointments

Based on LPA observation, interviews and file review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulation, Title 22 are being cited on the attached LIC9099D.

Exit Interview Conducted with assistant administrator Jasmin Tomines/ Appeal Rights Provided / A Copy of the Report Issued
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST 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 3
Control Number 28-AS-20220801140638
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
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Plan of Operation
(K)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 will rescind visitation schedule with C1 family member.Licensee will resFacility administrator will review plan of operation and abide with visitation regulation, that allows all family members to visit at any time. Licensee will provide in-service training to staff on visitation and provide a copy to LPA by POC date.
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Based on interviews, file review and observation, the facilty did not follow there plan of operation by requiring C1 family member to have schedule visits.This poses a potential health and safety risk to residents 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: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Jewel Baptiste
LICENSING PROGRAM ANALYST 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: 3 of 3