<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209076
Report Date: 03/02/2022
Date Signed: 03/14/2022 08:27:34 AM

Document Has Been Signed on 03/14/2022 08:27 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:G.L.O.M.A.R.F. 10FACILITY NUMBER:
247209076
ADMINISTRATOR:EVANS, LISAFACILITY TYPE:
735
ADDRESS:1259 LURS CTTELEPHONE:
(925) 570-3282
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY: 6CENSUS: DATE:
03/02/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lisa Evans, Licensee RepresentativeTIME COMPLETED:
11:00 AM
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
An Office Meeting was held via tele-conference on 03/02/2022 at the Fresno Regional Office to discuss the recent solvency audit that was completed by the Audit Section of CCLD.

The following were in attendance:

Lisa Evans, Licensee Representative, via Microsoft Teams

John Bishop, Licensee Representative, via Microsoft Teams

Krystall Moore, Regional Manager

Brenda White, Regional Manager

Jorge Mojica, CCL

Jude de la Concepcion, CCL

Yvonne Flores-Larios, CCL

Jacqueline Juarez, CCL

Liza King, Licensing Program Manager I

Stephenie Doub, Licensing Program Manager I

Sergiy Pidgirny, Licensing Program Manager I,

Lady Cabrera, Licensing Program Analyst

The financial information received and reviewed by the Audit Section shows that the Licensee's does not have an adequate financial plan in place.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/02/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: G.L.O.M.A.R.F. 10
FACILITY NUMBER: 247209076
VISIT DATE: 03/02/2022
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
26
27
28
29
30
31
32
CCLD Audits Section recommends that the Sacramento Regional Office cite the licensee for:

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

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

The Audit Section recommends quarterly Financial Monitoring for a period of one year or until it is evident that the licensee has an adequate financial plan in place. The first due date to CCLD Audits Section being by March 16, 2022:

Proof of payment of the $260K federal tax liens; An annual budget showing all anticipated income and expenditures for the organization as a whole, projected for 12 months beginning April 1, 2022 through March 31, 2023;

By the 3rd week following each quarter of the period, beginning April 1, 2022 through March 31, 2023, provide to Audits Section an income statement for the 3rd month of the quarter.

For example, the income statement and accompanying support for the quarter ending June 30, 2022 are due to Audits Section by close-of-business July 21, 2022.

Source documents used to prepare the income statement must be provided. Auditor must be able to trace and confirm reported revenues and expenditures to source documents provided.

Quarterly financial reporting is to continue for a period of 1 year, or until it is evident that the licensee has a financial plan that satisfies CCR Section 80062. During the monitoring phase, Audits to confirm noted liens ($260,000) are paid.

Licensee Representative agreed to submit the missing documents for the change of Administrator packet to CCL.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/14/2022 08:27 AM - It Cannot Be Edited


Created By: Lady Cabrera On 03/02/2022 at 10:38 AM
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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: G.L.O.M.A.R.F. 10
FACILITY NUMBER: 247209076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/16/2022
Section Cited
CCR
80062(a)(1)

1
2
3
4
5
6
7
80062 Finances (a) The licensee shall meet the following financial requirements:
(1) Development and maintenance of a financial plan which ensures resources necessary meet operating costs for care and supervision of clients.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee shall submit a Plan of Correction (POC) by POC due date 3/16/22. 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 03/02/22.
8
9
10
11
12
13
14
Based on records review 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.
8
9
10
11
12
13
14
Request Denied
Type B
03/16/2022
Section Cited
CCR80063(a)(1)

1
2
3
4
5
6
7
80063 Accountability(a)The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.(1) If the licensee is a corporation or an association, the governing body shall be active...This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee shall submit a Plan of Correction (POC) by POC due date 3/16/22. 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 03/02/22.
8
9
10
11
12
13
14
Based on records review 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.
8
9
10
11
12
13
14
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3