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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200842
Report Date: 02/17/2023
Date Signed: 02/17/2023 02:55:45 PM

Document Has Been Signed on 02/17/2023 02:55 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: 5DATE:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Jessica Turner, Program DirectorTIME COMPLETED:
02:30 PM
NARRATIVE
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On 2/17/2023 at 1:35PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Program Director, Jessica Turner.

Upon entry, LPA's temperature was checked and asked to complete COVID-19 questionnaire. LPA observed hand sanitizer at screening station. LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen, garage, and outdoor area. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations.

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 1:45PM, LPA measured hot water at 124.4 degrees F in the hallway bathroom sink.

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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2023
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 02/17/2023 02:55 PM - It Cannot Be Edited


Created By: Grace Luk On 02/17/2023 at 02:35 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: 02/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(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
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Based on observation, the licensee did not comply with the section cited above by having hot water at 124.4 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/18/2023
Plan of Correction
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Program Director has agreed to turn down hot water temperature and submit picture correction to CCLD by POC date.
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 Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023


LIC809 (FAS) - (06/04)
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