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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200678
Report Date: 04/30/2025
Date Signed: 04/30/2025 01:08:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250113085356
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:
04/30/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Latanya Austin, Program Director
Tyrone Titus, Facility Manager		TIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Staff did not allow resident access to their inhaler
INVESTIGATION FINDINGS:
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On 4/30/2025 at 9:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with Facility Manager, Tyrone Titus and informed him the reason for visit. Program Director, Latanya Austin arrive a couple hours later.

During the course of investigation, LPA interviewed 6 clients, 4 staff, witness, and complainant. LPA reviewed and obtained documents including staff roster with contact information, emergency information, physician's report, care plan, facility notes, Medication Administration Record (MAR), medication list, and incident reports.

Interview with client and staff revealed that S4 refused staff and/or client to go back to the facility for an inhaler when C5 had an asthma attack. C5's MAR and medication list indicated that C5 had an order for Albuterol inhaler with direction of inhale 2 puffs into lungs every 4 hours as needed for shortness of breath or wheezing. (Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
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 15-AS-20250113085356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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. ARF
FACILITY NUMBER: 019200678
VISIT DATE: 04/30/2025
NARRATIVE
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Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted with Latanya Austin. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250113085356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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. ARF
FACILITY NUMBER: 019200678
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2025
Section Cited
CCR
80075(b)(5)(B)
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Health Related Services. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by:
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Facility has agreed to create a plan or conduct training for staff on medication administration and submit the plan or staff training to CCLD by POC date.
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Based on interviews, licensee did not comply with the section cited above by not providing PRN medication according to the physician's directions which poses an immediate health and safety risk to the 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: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3