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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200842
Report Date: 03/20/2024
Date Signed: 03/20/2024 12:28:40 PM

Document Has Been Signed on 03/20/2024 12:28 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:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jessica Turner, Program Director
Alexandria Archangel, Administrator		TIME COMPLETED:
12:45 PM
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On 3/20/2024 at 8:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Program Director, Jessica Turner and explained the purpose of the visit. Administrator, Alexandria Archangel arrived 30 minutes later. The facility’s fire clearance was approved for 6 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, common area, 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. Last fire drill was conducted on 3/1/2024.

LPA reviewed 4 clients and 3 staff files starting at 9:30AM. LPA reviewed a sample of client's medications starting at 11:30AM. LPA interviewed 2 clients and 2 staff starting at 12:00PM.

At 9:25AM, LPA measured hot water at 132.4 degrees F in the hallway bathroom. Staff lowered hot water and LPA re-measured hot water at 115.3 degrees F.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency 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: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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 03/20/2024 12:28 PM - It Cannot Be Edited


Created By: Grace Luk On 03/20/2024 at 12:19 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: 03/20/2024

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 132.4 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/21/2024
Plan of Correction
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Staff lowered hot water and LPA re-measure hot water at 115.3 degrees F 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 Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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