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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200842
Report Date: 12/27/2024
Date Signed: 12/27/2024 11:13:51 AM

Document Has Been Signed on 12/27/2024 11:13 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. ARF 2FACILITY NUMBER:
019200842
ADMINISTRATOR/
DIRECTOR:		TURNER, ALLENFACILITY TYPE:
735
ADDRESS:1885 WALNUT STREETTELEPHONE:
(925) 583-5555
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 6CENSUS: 5DATE:
12/27/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Ken Manu, Program AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 12/27/2024 at 9:10AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received for C1. LPA met with staff, Angela Anderson and explained the purpose of the visit. Program Administrator, Ken Manu arrived 15 minutes later.

Death report revealed that C1 was calling for help after a fall. C1 was found seated on the floor in front of the bathroom. C1 was unresponsive and staff called 911 immediately. Staff performed CPR and emergency responders arrived about 5 minutes later. Emergency responder pronounced death on 11/22/2024.

LPA interviewed a client and staff. LPA reviewed and obtained documents including physician's report, care plan, preplacement appraisal, after visit notes, incident report, facility notes, police report information, MAR, and medication list.

LPA may return at a later time.

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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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