392700168-4-16-2023-27-AS-AJON-CQY5ZH-20230416202358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700168
Report Date: 03/24/2023
Date Signed: 04/16/2023 08:24:06 PM

Document Has Been Signed on 04/16/2023 08:24 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	GM ARF, LLC		FACILITY NUMBER:	392700168
ADMINISTRATOR:	GUMAGAY, GRIFFIN		FACILITY TYPE:	735
ADDRESS:	2797 VERSTL WAY		TELEPHONE:	(916) 706-8427
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 5		CENSUS: 5	DATE:	03/24/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Danilo Mabalot and Mirafe Mula		TIME COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Albert Johnson arrived at this facility unannounced to conduct a case management visit. LPA met with Staff explained the purpose of the visit.

On 2/22/23 Consumer stated that staff entered the bathroom without permission while he was showering. Staff allegedly entered multiple times and moved stuff in his room while he was bathing. Consumer alleges that his charger for his game console is now missing.

LPA was able to determine that the facility staff was unaware that the curtain to the bathroom was open and R1 was showering with the curtains to the shower open as well causing the floor of the bathroom to flood. Staff stated that the door of the room was closed and they knocked on the door, however R1 did not responded so staff entered and that is when R1 saw the staff and told them to get out. The staff left the room and reminded R1 to close the shower door when taking a shower to prevent the bathroom from flooding and lessening the risk of R1 slipping and falling.

LPA also observed an expired IPP for R1. The facility will request that the IPP be updated to address the need to follow house rules and maintain safety awareness while taking a shower, closing the curtain to keep the floor from flooding and reducing the risk of a slip and fall for residents and staff.

No deficiencies are being cited per Tittle 22 Regulations.

An exit interview was conducted

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2023

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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