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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200842
Report Date: 03/18/2022
Date Signed: 03/18/2022 03:12:26 PM

Document Has Been Signed on 03/18/2022 03:12 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 2FACILITY NUMBER:
019200842
ADMINISTRATOR:TURNER, ALLENFACILITY TYPE:
735
ADDRESS:1885 WALNUT STREETTELEPHONE:
(925) 583-5555
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 6CENSUS: 6DATE:
03/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jessica Turner, Program DirectorTIME COMPLETED:
03:30 PM
NARRATIVE
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On 3/18/2022 at 3:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Program Director, Jessica Turner.

This case management visit to continue the report dated 3/2/2022 where an office meeting was conducted in the Sacramento Regional Office via Microsoft Teams.

The licensee is cited for the following deficiencies:

CCR, Title 22, Division 6, Chapter 8, Section 80062 Finances

CCR, Title 22, Division 6, Chapter 8, Section 80063 Accountability

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies 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: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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 03/18/2022 03:12 PM - It Cannot Be Edited


Created By: Grace Luk On 03/18/2022 at 03:06 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 2
FACILITY NUMBER: 019200842

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2022
Section Cited
CCR
80062(a)(1)

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Finances. Development and maintenance of a financial plan which ensures resources necessary meet operating costs for care and supervision of clients. This requirement is not met as evidence by:
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Licensee shall submit a Plan of Correction (POC) by POC due date. The POC shall be a written statement by the Licensee that Licensee will comply with all audit recommendations outlined in the financial audit that was presented to the Licensee on 3/2/2022.
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Based on records reviewed and interviews, the licensee was not incompliance with the Title 22 Regulation, which poses a potential Health, Safety and Personal Rights risks to persons in care.
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Type B
03/21/2022
Section Cited
CCR80063(a)(1)

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Accountability. If the licensee is a corporation or an association, the governing body shall be active and functioning in order to ensure such accountability. This requirement is not met as evidence by:
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Licensee shall submit a Plan of Correction (POC) by POC due date. The POC shall be a written statement by the Licensee that Licensee will comply with all audit recommendations outlined in the financial audit that was presented to the Licensee on 3/2/2022.
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Based on records reviewed and interviews, the Licensee was not incompliance with the Title 22 Regulation, which poses a potential Health, Safety and Personal Rights 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022


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