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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374602117
Report Date: 10/08/2021
Date Signed: 10/08/2021 04:51:31 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2020 and conducted by Evaluator Lizzette Tellez
COMPLAINT CONTROL NUMBER: 08-AS-20200505150949
FACILITY NAME:TOMAS RESIDENTIAL CAREFACILITY NUMBER:
374602117
ADMINISTRATOR:NORMA TOMASFACILITY TYPE:
740
ADDRESS:6344 JOUGLARD STTELEPHONE:
(619) 434-5235
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:6CENSUS: 3DATE:
10/08/2021
UNANNOUNCEDTIME BEGAN:
03:32 PM
MET WITH:Licensee, Abraham Tomas, and Administrator Norma TomasTIME COMPLETED:
04:16 PM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lizzette Tellez conducted an unannounced complaint visit to deliver findings on the above-mentioned allegation. LPA was met by Administrator, Norma Tomas, and discussed the purpose of the visit. Licensee, Abraham Tomas arrived during the visit.

Investigation consisted of interviews with staff and outside sources, record review, and a tour of the facility. It was alleged that Resident #1 (R1) was unlawfully evicted from the facility. Mr. Tomas was provided with Confidential Names Form in order to identify R1. Facility record review and investigative interviews revealed that on March 11, 2020, R1 was served with a written 60-day eviction notice which noted the reasons for eviction as non-compliance with house rules, specifically that R1 is non-compliant with their medication regimen, and health and safety concerns, such as cooking during overnight hours. Interviews and record review revealed R1 is non-compliant with their medication regimen, and a reappraisal of R1’s needs was not conducted prior to the date of the eviction notice. Review of the house rules revealed non-compliance with medication regimens is not part of the facility's house rules.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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 08-AS-20200505150949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TOMAS RESIDENTIAL CARE
FACILITY NUMBER: 374602117
VISIT DATE: 10/08/2021
NARRATIVE
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 Additionally, the eviction notice did not include the required statements and resources, and a written copy was not provided to the resident’s designated representative. The Department has investigated the allegation of illegal eviction and has found that, based upon record review and interviews, the preponderance of the evidence standard has been met. Therefore, this allegation is deemed substantiated.

This deficiency is noted on the attached 9099-D and is cited in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with Mr. Tomas and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20200505150949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: TOMAS RESIDENTIAL CARE
FACILITY NUMBER: 374602117
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2021
Section Cited
CCR
87224(a)(4)
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EVICTION PROCEDURES
If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement was not met as evidenced by:
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Updated reappraisal of R1 was completed. Licensee stated a corrected and lawful 30-day eviction notice will be provided to R1 and their designated representative, and a copy provided to CCL by POC date.
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Based upon record review and interviews, the licensee did not serve a lawful written 30-day eviction notice and did not conduct a reappraisal of the resident prior to issuing the notice. This posed a potential personal rights risk to one (R1) of six 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.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/05/2020 and conducted by Evaluator Lizzette Tellez
COMPLAINT CONTROL NUMBER: 08-AS-20200505150949

FACILITY NAME:TOMAS RESIDENTIAL CAREFACILITY NUMBER:
374602117
ADMINISTRATOR:NORMA TOMASFACILITY TYPE:
740
ADDRESS:6344 JOUGLARD STTELEPHONE:
(619) 434-5235
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY:6CENSUS: DATE:
10/08/2021
UNANNOUNCEDTIME BEGAN:
03:32 PM
MET WITH:Licensee, Abraham Tomas, and Administrator Norma TomasTIME COMPLETED:
04:16 PM
ALLEGATION(S):
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Facility staff was not ensuring that resident took medications as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lizzette Tellez conducted an unannounced complaint visit to deliver findings on the above-mentioned allegation. LPA was met by Administrator, Norma Tomas, and discussed the purpose of the visit. Licensee, Abraham Tomas, arrived during the visit.

Investigation consisted of interviews with staff and outside sources, record review, and a tour of the facility. It was alleged that facility staff were not ensuring that Resident #1 (R1) took medications as prescribed. Investigative interviews revealed that R1 has been refusing medication since February 12, 2020 and has not gone to their day program since ending conservatorship. R1’s designated representative confirmed receiving notice that R1 has been non-compliant with medication regimen and indicated that R1's mental health has declined. Interviews with residents, including R1, were inconsistent regarding assistance with medications. R1's centrally stored medications and Medication Administration Records (MARs) were reviewed and did not yield discrepancies.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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 08-AS-20200505150949
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: TOMAS RESIDENTIAL CARE
FACILITY NUMBER: 374602117
VISIT DATE: 10/08/2021
NARRATIVE
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This Department has investigated the above-mentioned allegation and has found that, based upon the evidence gathered during the investigation, there is insufficient evidence to corroborate the allegation. Therefore, this allegation is deemed unsubstantiated.

An exit interview was conducted with Mr. Tomas and a copy of this report, along with Licensee Rights (LIC 9058 01/16), were provided to the Administrator via email. An electronic receipt of confirmation was requested to be sent by the Administrator upon receipt of the documents.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5