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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700168
Report Date: 07/08/2025
Date Signed: 07/08/2025 11:38:13 AM

Document Has Been Signed on 07/08/2025 11:38 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GM ARF, LLCFACILITY NUMBER:
392700168
ADMINISTRATOR/
DIRECTOR:		GUMAGAY, GRIFFINFACILITY TYPE:
735
ADDRESS:2797 VERSTL WAYTELEPHONE:
(916) 706-8427
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 5CENSUS: 5DATE:
07/08/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Christine Joy ArcegaTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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on 7/8/25 at 9:45, Licensing Program Analyst(LPA) Noel Wolf Petersen arrived unannounced to conduct an inspection of conditions and care related to the PEG tubing resident and met with Christine Joy Arcega, a staff member, and explained the purpose of the visit. The facility is a Adult Residential Facility with a capacity of 5 clients and 5 clients currently in the facility, 1 non-ambulatory, and 4 ambulatory. A client with a restricted condition is currently working on an exemption for a peg-tube, no other restricted conditions are amongst the current population of clients.

A physical inspection was completed, including but not limited to common areas, exteriors, evacutation routes, kitchen, storage areas, the client bed rooms and bathrooms. Required furniture and furnishings of the bathrooms, bedrooms, and common areas are present and in good repair. The facility is well lit, and traffic areas are unobstructed. all required postings are present including the facility sketch, federal work rights, the vmrc rights poster, and the administrator certification and facility license. LPA pointed out the ombudsman poster has a particular dimension in the regulation, and the staff provided that it would be replaced. Sharps and medications were stored locked, and although some of the hand soaps and sanitizers were left out and could potentially present a hazard if consumed, no client currently in the facilities care is specifically unable to handle hygiene products unsupervised in their physicians report while being unsupervised in the bathroom. The staff provided it would still be prudent to switch to non-toxic soap. LPA observed one of the two indicated fire exits has a gate that is somewhat difficult to open due to dragging into the concrete and needs to be rehung. Staff noted some repair would be made, while pointing out the second gate was fine.

Continued on C. Page
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GM ARF, LLC
FACILITY NUMBER: 392700168
VISIT DATE: 07/08/2025
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A review of the records was conducted specific to the concerns with the resident with the Peg tube, documents are in order.

While initially the LPA arrived to conduct a annual visit, the LPA is early to the inspection window and can't yet enter an annual inspection into FAS, a second inspection will have to occur in the near future involving a interview of more clients and staff and to review the administrator documents, the scope of this case management was kept to the physical inspection and observation of the care and conditions related to the Peg tube; of which performance is nominal.

Per title 22, no citations were issued this visit.

An exit interview was conducted and a copy of the report was red and left with the staff.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2025
LIC809 (FAS) - (06/04)
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