019200678-12-21-2023-15-AS-GLUK-CYQUJ2-20231221143650

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200678
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:37:01 PM

Document Has Been Signed on 12/21/2023 02:37 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:	G.L.O.M. ARF		FACILITY NUMBER:	019200678
ADMINISTRATOR:	TURNER, ALLEN DR		FACILITY TYPE:	735
ADDRESS:	2066 WALNUT STREET		TELEPHONE:	(925) 583-5775
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94551
CAPACITY: 6		CENSUS: 6	DATE:	12/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Jessica Turner, Program Director Ken Manu, Program Administrator		TIME COMPLETED:	02:50 PM

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	Attempted visit was made on 12/14/2023 at 9:40AM, by Licensing Program Analyst (LPA) G. Luk. On 12/21/2023 at 8:50AM, Licensing Program Analysts (LPAs) G. Luk and T. Syess-Gibson arrived unannounced to conduct a Required - 1 Year inspection. LPAs met with Program Administrator, Ken Manu and explained the purpose of the visit. Program Director, Jessica Turner arrived 3 hours later. The facility’s fire clearance was approved for 6 ambulatory clients. LPAs toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 7/7/2023. One week of nonperishable and 2-day of perishable food supplies were available. There were adequate lights in each room. First Aid kit is complete. No bodies of water observed. Indoor and outdoor passageways were free of obstruction. LPAs reviewed 3 client and 3 staff files starting at 9:30AM. LPAs reviewed a sample of client's medications starting at 11:30AM. LPAs interviewed 2 clients and 2 staff starting at 1:00PM. At 9:15AM, LPAs observed unlocked cleaning supplies under the kitchen sink. Staff locked up the cleaning supplies during inspection. At 9:30AM, LPAs measured hot water temperature at 133.9 degrees F in the hallway bathroom. Staff lowered hot water temperature and LPAs remeasured hot water at 108.2 degrees F during inspection. At 10:36AM, LPAs observed unlocked medications in the refrigerator. Staff locked the lockbox during inspection. (Continue on LIC809C...)

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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 6

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
	VISIT DATE: 12/21/2023

NARRATIVE

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At 11:45AM, LPAs observed C1's medication bottle for Olanzapine has a label that was not readable. Staff showed LPAs a new bottle of C1's Olanzapine during inspection.

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

Exit interview conducted. A copy of this report and appeal rights were provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 12/21/2023 02:37 PM - It Cannot Be Edited

Created By: Grace Luk On 12/21/2023 at 01:42 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: G.L.O.M. ARF	FACILITY NUMBER: 019200678
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having cleaning supplies assessible which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Staff locked up the cleaning supplies during inspection. Deficiency cleared.

Type A

Section Cited

CCR

80088(e)(1)

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having hot water measured at 133.9 degrees F which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Staff lowered hot water temperature and LPAs remeasured hot water at 108.2 degrees F during inspection. Deficiency cleared.

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: 12/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 12/21/2023 02:37 PM - It Cannot Be Edited

Created By: Grace Luk On 12/21/2023 at 01:59 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: G.L.O.M. ARF	FACILITY NUMBER: 019200678
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(k)(1)

(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having unlocked medications in the refrigerator which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Staff locked medications in the lockbox during inspection. Deficiency cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 12/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 12/21/2023 02:37 PM - It Cannot Be Edited

Created By: Grace Luk On 12/21/2023 at 02:04 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: G.L.O.M. ARF	FACILITY NUMBER: 019200678
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(k)(3)

(k) The following requirements shall apply to medications which are centrally stored: (3) All medications shall be labeled and maintained in compliance with label instructions and state and federal laws. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by haivng unreadable medication label for C1 which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Staff showed LPAs a new bottle of medication (Olanzapine) with readable label during inspection. Deficency cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 12/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

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