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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803977
Report Date: 08/28/2025
Date Signed: 08/28/2025 03:13:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/23/2025 and conducted by Evaluator Anthony Loera
COMPLAINT CONTROL NUMBER: 21-AS-20250623094939
FACILITY NAME:JPS HOME CARE SERVICESFACILITY NUMBER:
486803977
ADMINISTRATOR:JULLY CARTELFACILITY TYPE:
740
ADDRESS:441 NORTH CAMINO ALTOTELEPHONE:
(707) 655-2264
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:6CENSUS: 6DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Olivia Pangilinen, CaregiverTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff are not providing adequate care and supervision of a resident
Staff are not meeting a resident's incontinence needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Loera arrived unannounced and met with Olivia Pangilinen, Caregiver to deliver findings of a complaint investigation. During the course of this investigation, documents were reviewed, outside record of videos were reviewed, observations made, and interviews conducted.

Complaint alleges staff are not providing adequate care and supervision of a resident and staff are not meeting a resident's incontinence needs.

Allegation, staff are not providing adequate care and supervision of a resident. During the investigation, outside video recordings and statements were reviewed, interviews conducted, and observations made. A review of a video recording of residents (R1 & R2) revealed that staff (S1) left R1 without assistance. S1 stated they were following behind R1 and R2 in the driveway, however whether S1 was following behind R1 and R2, video record shows R1 still needed assistance that they did not receive. Video shows R2 helping R1 sit in their wheelchair with no assistance from S1.

continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
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 3
Control Number 21-AS-20250623094939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: JPS HOME CARE SERVICES
FACILITY NUMBER: 486803977
VISIT DATE: 08/28/2025
NARRATIVE
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Complaint alleges staff are not meeting a resident’s incontinence needs, based on interviews that were conducted with facility staff and residents, and records reviewed, it was determined resident (R1) has difficulty functioning on their own as per their Needs and Service plan dated 03/31/2025 under physical/health. Interviews conducted with 2 of 3 residents state they have heard R1 at night calling for help for hours with no assistance from staff on duty to assist R1.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Division 6, Chapter1 is being cited on the attached LIC 9099D. Appeal rights given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250623094939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: JPS HOME CARE SERVICES
FACILITY NUMBER: 486803977
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2025
Section Cited
HSC
1569.269(a)(6)
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§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs...
This requirement is not met by licensee as evidence by video review and interviews......
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Facility will submit plan to CCL to conduct personal rights training and training for all direct care staff on care and supervision by plan of correction due date 08/29/2025. Facility to submit proof of completed training to CCL by 09/10/25.
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conducted, the licensee did not ensure R1 received assistance from S1 and/or staff on duty. This 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3