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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200678
Report Date: 12/08/2022
Date Signed: 12/08/2022 10:30:49 AM


Document Has Been Signed on 12/08/2022 10:30 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:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Jessica Turner, Program DirectorTIME COMPLETED:
10:45 AM
NARRATIVE
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On 12/8/2022 at 8:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with staff, Angela Anderson and explained the purpose of the visit. Program Director, Jessica Turner arrived 10 minutes later.

Upon entry, LPA's temperature was checked and asked to fill out COVID-19 questionnaire. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to bedrooms, bathroom, kitchen, common areas, storage shed, and outdoor area. LPA observed cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All bathrooms and sinks were equipped with soap and paper towel. Hand washing posters were posted in bathrooms. Hot water was measured at 116.6 degrees F in the hallway bathroom sink.

During record review, LPA observed visitors log and temperature log for staff & clients. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food, and paper supplies are sufficient.

At 9:05AM, LPA observed unlocked lighter in the kitchen drawer. LPA also observed unlocked laundry detergent in the laundry area. Staff locked up the lighter and the detergent during inspection.

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 this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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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Document Has Been Signed on 12/08/2022 10:30 AM - It Cannot Be Edited

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: G.L.O.M. ARF
FACILITY NUMBER: 019200678

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having unlocked lighter and detergent which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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Staff locked up the lighter and detergent during inspection.

Deficiency cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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