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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600340
Report Date: 04/24/2024
Date Signed: 04/24/2024 12:09:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/14/2024 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240214183731
FACILITY NAME:RJ STARLIGHT HOME CORPORATIONFACILITY NUMBER:
385600340
ADMINISTRATOR:TERESITA JOMOKFACILITY TYPE:
740
ADDRESS:2680 BRYANT STREETTELEPHONE:
(415) 648-2280
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:12CENSUS: 11DATE:
04/24/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Caregiver, Lorna GonzalesTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Facility has pests.
INVESTIGATION FINDINGS:
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On April 24, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver complaint investigation findings. LPA met with caregiver and explained the purpose of today's visit.

Regarding to allegation of- facility has pests, the reporting party stated that he/she witnessed resident scratching themselves and reporting party also reported that facility has bedbugs.

As part of the investigation, LPA interview resident in question(R1), staff and administrator.

The administrator acknowledged that the facility has bedbugs and it has been a chronic problem. In addition, the administrator stated that they have been getting monthly pest control services from Terminix to treat the bedbugs.

LPA interviewed staff #1 (S1) who acknowledged that there is bedbugs in some of the resident's room and they clean the rooms everyday but the bedbugs remain. In addition, S1 stated that Terminix comes to the facility frequently to treat the bedbugs.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
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 7
Control Number 14-AS-20240214183731
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RJ STARLIGHT HOME CORPORATION
FACILITY NUMBER: 385600340
VISIT DATE: 04/24/2024
NARRATIVE
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LPA interviewed R1 who stated that there is bedbugs on his/her mattress and he/she gets bit all the time at night.

Based on documents provided by the facility, LPA observed Terminix services were provided on a regular basis.

After the investigation, this allegation is deemed to be substantiated. Although the facility has regular Terminix services to treat the bedbugs and daily cleaning by staff, residents are still being affected.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with caregiver and Administrator who was on the phone.

A copy of this report and the Appeal Rights provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 14-AS-20240214183731
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: RJ STARLIGHT HOME CORPORATION
FACILITY NUMBER: 385600340
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation..(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
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The administrator/licensee shall develop a plan to ensure the facility is cleaned, safe and sanitary to all residents. The plan shall have a different intervention as the current plan is not working.
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Based on observation, record review and interview, facility has bedbugs which poses an immediate health and safety risks to residents in care.
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 The administrator will submit a copy of the plan to CCL by 4/25/2024.
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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.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/14/2024 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240214183731

FACILITY NAME:RJ STARLIGHT HOME CORPORATIONFACILITY NUMBER:
385600340
ADMINISTRATOR:TERESITA JOMOKFACILITY TYPE:
740
ADDRESS:2680 BRYANT STREETTELEPHONE:
(415) 648-2280
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:12CENSUS: 11DATE:
04/24/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Caregiver, Lorna GonzalesTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Resident was assaulted by another resident while in care.
Staff are not ensuring that a resident is able to sleep at night.
INVESTIGATION FINDINGS:
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On April 24, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver complaint investigation findings. LPA met with caregiver and explained the purpose of today's visit.

Regarding to the allegation of- resident was assaulted by another resident while in care, the reporting party stated that resident-in-question (R1) was hit by his/her roommate, resident #2 (R2).

As part of the investigation, LPA interviewed R1, administrator and staff.

LPA interviewed R1 who stated he/she was hit by R2 and stated that they have been roommates for a couple of years and this has never happened before. R1 also stated that R2 has bad tempers and uses foul language often.

According to the administrator, R1 and R2 have been roommates for a couple of years and this incident has never happened before. When it happened, the staff notified her immediately and they assessed R1 for injuries, called the local law enforcement, informed R1's responsible party and CCL.

In addition, the administrator stated that to prevent this incident from happening again, she has proposed different interventions such as offered R1 and R2 room transfers and offered R1 to move to another facility. However, both of them did not want to be moved. In addition, the administrator is working with Public Health Social Worker to locate another facility for R2.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
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 7
Control Number 14-AS-20240214183731
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RJ STARLIGHT HOME CORPORATION
FACILITY NUMBER: 385600340
VISIT DATE: 04/24/2024
NARRATIVE
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According to staff #1(S1) who was at the facility during the incident. When R1 reported being hit by R2, S1 called the administrator immediately and reported the incident. S1 stated that they are monitoring both residents more frequently but it could be a challenge as both residents are ambulatory, and they come and go as they please.

After the investigation, this allegation is deemed to be unsubstantiated as R1 was hit by R2 on January 11, 2024. However, there is no indication of staff neglect as residents are ambulatory, physician's orders stated that they could leave the facility unassisted and they come and go multiple times on a daily basis.

Regarding to the allegation of - staff are not ensuring that a resident is able to sleep at night, the reporting party stated that R1 is unable to sleep as R2 returns to the facility sometimes late at night after roaming around the city.

As part of the investigation, LPA interviewed the administrator and R1.

According to the administrator, both residents are ambulatory and they can leave the facility unassisted. R2 leaves the facility everyday and R2 goes in and out of the facility frequently to smoke so R2 may be disturbing R1's sleep. The administrator has offered both of them room transfers but they declined. The administrator discussed room transfer with R1's responsible party who also declined. The administrator offered R1 to move to another facility and it was also declined and currently, the administrator is working with Public Health SW on seeking a different facility for R2.

After the investigation, this allegation is deemed to be unsubstantiated as the facility offered different interventions to ensure R1 gets sleep at night, however, all of them were declined by R1 and R1's responsible party. The administrator is working with Public Health SW to seek for another facility for R2.

Although the above investigations 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.

This report is reviewed and discussed with caregiver and administrator on the phone.
A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/14/2024 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240214183731

FACILITY NAME:RJ STARLIGHT HOME CORPORATIONFACILITY NUMBER:
385600340
ADMINISTRATOR:TERESITA JOMOKFACILITY TYPE:
740
ADDRESS:2680 BRYANT STREETTELEPHONE:
(415) 648-2280
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:12CENSUS: 11DATE:
04/24/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Caregiver, Lorna GonzalesTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Facility did not fulfill reporting requirements.
Facility is illegally evicting a resident from the facility
INVESTIGATION FINDINGS:
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On April 24, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver complaint investigation findings. LPA met with caregiver and explained the purpose of today's visit.

Regarding to the allegation of facility did not fulfill reporting requirement- the reporting party reported that there was an incident happened on January 11, 2024, resident #1 (R1) was hit by resident #2 (R2) and it was not reported to CCL.

As part of the investigation, LPA interviewed the administrator who denied the allegation and stated that this incident was reported to CCL via fax on January 17, 2024.

Based on the faxed confirmation provided by the administrator, it revealed that the facility reported the incident to CCL on time.

After the investigation, this allegation is deemed to be unfounded.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 14-AS-20240214183731
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RJ STARLIGHT HOME CORPORATION
FACILITY NUMBER: 385600340
VISIT DATE: 04/24/2024
NARRATIVE
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Regarding to the allegation of - facility is illegally evicting a resident from the facility, the reporting party stated that the facility is trying to evict R2 as R2 assaulted R1 on January 11, 2024.

As part of the investigation, LPA interviewed the administrator who stated that the facility was advised by SF Department of Public Health Social Worker to issue an 3-day eviction notification to R2 and the administrator generated the letter and faxed it to CCL for approval. However, the letter was never given to R2 as the administrator did not get an approval from CCL. In addition, the administrator stated that they are working with SF Public Health to discharge R2.

During the 10-day visit, LPA attempted to interviewed R2 but R2 did not want to be interviewed.

Based on documents provided by the administrator, the facility faxed the eviction notification CCL for approval and the notification was not presented to R2 because an approval was not obtained from CCL.

After the investigation, this allegation is deemed to be unfounded because the facility requested an approval from CCL prior to delivering a 3-day eviction notification for R2 and it was not given to R2 as it was not approved by CCL.

Based on interviews, the department has determined that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

This report is reviewed and discussed with caregiver and administrator over the phone. .
A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7