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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600340
Report Date: 01/22/2025
Date Signed: 01/22/2025 10:37:50 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
10/25/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 14-AS-20241025153119
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: 10DATE:
01/22/2025
UNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Amelia Arcincas, Lead StaffTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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On 1/22/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Amelia Arcinas, Lead Staff. LPA toured the facility, interviewed residents, staff and outside parties, reviewed resident records, and made observations during the course of the investigation.

Complaint alleges an illegal eviction towards resident (R1). Upon interviews with staff (S1 & S2), residents (R2 & R3) it was indicated that R1 had left the facility voluntarily and further stated that R1 was highly verbally aggressive towards staff and other residents. S1 further explained that the facility did not evict R1 but was R1’s decision to leave the facility with no further contact. The facility followed with appropriate reporting requirements from the incident. Reviewing R1’s medical assessment indicated that R1 can leave the facility unassisted.

Additional interview with San Francisco Department of Public Health Social Worker, (I2) confirmed that R1 had left the facility voluntarily with no notice or contact to either the facility or I2. I2 is responsible for R1’s placement and indicated that R1 had left San Francisco area for approximately 1 month and returned around 10/25/2024. I2 stated that during the time frame that R1 was unable to be located; R1’s placement at the facility was ended by I2 after a two week hold on R1’s placement in case R1 returned. Upon R1’s return and contact with I2; R1 was admitted into a temporary shelter located in San Francisco. I2 stated that they were in the process of completing a medical assessment for R1, required for DPH clearance when transferring into another long term care facility. I2 further stated that R1 was not cooperative with completing the medical assessment, delaying R1 in being properly placed in a new facility.
Continued onto LIC909-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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 2
Control Number 14-AS-20241025153119
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: RJ STARLIGHT HOME CORPORATION
FACILITY NUMBER: 385600340
VISIT DATE: 01/22/2025
NARRATIVE
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The agency has investigated the allegation and we have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted. This report was reviewed with the Director and a copy of the report left at the facility. No deficiency cited.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2