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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200976
Report Date: 06/25/2026
Date Signed: 06/25/2026 03:33:58 PM

Document Has Been Signed on 06/25/2026 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JANGA CARE HOMEFACILITY NUMBER:
079200976
ADMINISTRATOR/
DIRECTOR:		KOLLIE, COMFORT K.FACILITY TYPE:
740
ADDRESS:3601 GENTRYTOWN DRTELEPHONE:
(510) 677-3734
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 4DATE:
06/25/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:25 AM
MET WITH:Kumba Quermollu/Staff TIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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While at the facility conducting investigation of a complaint (Complaint Control # 15-AS-20260618105114), LPA conducted inspection with staff, Kumba Quemollu and upon review of residents' records, Licensing Program Analyst (LPA) Delmundo observed the following:
  • at 11:36 am, mattress, broken glass closet door, detached fenced wood plank in the side yard. Side fence gate pad locked.
  • at 11:37 am, broken folded chair blocking the fence gate and plywood in the backyard. Fence gate pad locked.
  • at 11:40 am, closet door missing in one of the resident's rooms of which the staff stated the glass closet door was broken by the resident sometime in December 2025.
  • at 11:50 am, dowel on the sliding exit door in the resident room preventing the door to be opened.
  • at 11:52 am, razor in the ensuite bathroom.
  • at diaper rash ointment in one of the resident's room where dowel was observed.
  • at 11:56 pm, transitions strips on the flooring all throughout the facility were missing of which tape were used.
  • three (3) out of 4 residents' LIC601 Identification and Emergency Contact Information were not filed-up properly - either left blank or indicated N/A on the following: resident's name; responsible person; name of nearest relative date admitted to the facility; date left; reason(s) for leaving. The other 1 residents does not have LIC601 on file.
  • all 3 entrance and exit doors' auditory signals not working.
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...continued on 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: JANGA CARE HOME
FACILITY NUMBER: 079200976
VISIT DATE: 06/25/2026
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CONTINUATION FROM PAGE 1:

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section 87203. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in additional civil penalties.

Deficiencies, plan and proof of corrections and civil penalty were with the administrator (ADM) over the phone. ADM gave authorization for Kombu Quermollu to sign and receive this report.



Exit interview conducted. Appeal Rights, LIC421IM, LIC9098 Proof of Correction form, and copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Alicia Delmundo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 06/25/2026 03:33 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/25/2026 at 02:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JANGA CARE HOME
FACILITY NUMBER: 079200976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2026
Section Cited
CCR
87203

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

-This requirement is not met as evidenced by:
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Staff removed the padlocks and dowel while LPA was at the facilty.

Adminsitrator to do the folllowing and submit proof by 6/26/26:
1. Read the Regulation and submit self-certification of understanding.
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-Based on observation, the licensee did not comply with the section above in locked fence gates, chair blocking the fence gate and dowel in the sliding door which pose an immediate safety risks to the persons in care.
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2. In-service the staff and submit copy of training topic with attendees signatures.

A $500.00 civil penalty is assessed.
Type A
06/26/2026
Section Cited
CCR87309(a)

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87309 Storage Space and Access
(a)...... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended.......
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Staff locked the items.
In addition, administrator to In-service the staff and submit copy of training topic(s) with attendees signatures by 6/26/26.
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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above in unlocked razor and ointment in the resident's room which pose an immediate safety risks 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2026 03:33 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/25/2026 at 02:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JANGA CARE HOME
FACILITY NUMBER: 079200976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2026
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. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Administrator to do the following and submit pictures by 7/09/26:
1. Have the yard cleaned.
2. Have the fence repaired.
3. Have the tape removed from the flooring and replace with transition strips.
4. Closet door installed.
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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above in the following which pose a potential safety, and/or personal rights risks to persons in care: mattress, broken glass closet door, detached fenced wood plank in the side yard; missing closet door; transition strips missing
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Type B
07/09/2026
Section Cited
CCR87506(a)

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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
-This requirement is not met as evidenced by:
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Licensee to complete the LIC601s and submit copies by 7/09/26.
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-Based on records review, the licensee did not comply with the section above in 3 of residents' LIC601 not properly filed-up and 1 resident has no LIC601 on file which pose a potential 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2026 03:33 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 06/25/2026 at 03:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JANGA CARE HOME
FACILITY NUMBER: 079200976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/26/2026
Section Cited
CCR
87705(d)

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87705 Care of Persons with Dementia
(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions.
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Administrator to have the auditory signals checked and install new batteries, otherwise replace with new ones. Proof to be submitted by 6/26/26.
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-This requirement is not met as evidenced by:
-Based on observation, the licensee did not comply with the section above in having auditory signals on 3 doors not working which pose an immediate safety 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Alicia Delmundo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2026


LIC809 (FAS) - (06/04)
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