<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200678
Report Date: 04/12/2022
Date Signed: 04/12/2022 09:55:37 AM

Document Has Been Signed on 04/12/2022 09:55 AM - 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:G.L.O.M. ARFFACILITY NUMBER:
019200678
ADMINISTRATOR:TURNER, ALLEN DRFACILITY TYPE:
735
ADDRESS:2066 WALNUT STREETTELEPHONE:
(925) 583-5775
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 6CENSUS: 6DATE:
04/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica Turner, Program DirectorTIME COMPLETED:
10:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/12/2022 at 9:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Program Director, Jessica Turner.

While LPA was at the facility for another visit, LPA observed that S1 was not fingerprint cleared and have been working at the facility for a couple months.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.



Exit interview conducted. A copy of report and Appeal Rights were provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/12/2022 09:55 AM - It Cannot Be Edited


Created By: Grace Luk On 04/12/2022 at 09:40 AM
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: G.L.O.M. ARF
FACILITY NUMBER: 019200678

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2022
Section Cited
CCR
80019(e)(1)

1
2
3
4
5
6
7
Criminal Record Clearance
Obtain a California clearance or a criminal record exemption as required by the Department...
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Program director have asked S1 to leave for the day and will make sure that staff is cleared prior to returning to work. Program director will contact Care Provider Management Bureau and provide documentation to CCLD by POC date.
8
9
10
11
12
13
14
Based on record review, licensee did not comply with the section cited above by having an uncleared staff working at the facility which poses an immediate health and safety risk to the persons in care.
8
9
10
11
12
13
14
Civil penalty of $500 is being assessed.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2