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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700168
Report Date: 10/29/2025
Date Signed: 10/29/2025 03:24:18 PM

Document Has Been Signed on 10/29/2025 03:24 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
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:
10/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Vita GobagaiTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst, LPA, Noel Wolf Petersen, arrived unannounced at 1:45pm on 10/29/25 to conduct an annual inspection. LPA met with Vita Gumagay to explain the purpose of the visit, GM arf, llc is a 5 capacity adult residential facility for M/f 18-59. no current waiver and exceptions for clients in care. there are 4 ambulatory, 1 nonambulatory, 0 bedridden.

Physical Plant was inspected including the kitchen, common areas, bathrooms, bedrooms, exteriors, evacuation route. The facility is clean, the traffic areas are unobstructed and well lit. The kitchen has adquate storage for sharps, medication and toxics. common areas and exteriors are free of trip hazards and have adquate space for activites. bathrooms have hardware in good repair, water is delivered between 105-120. The bedrooms have required furniture and furnishings. evacuation routes are in good repair.

2 clients mars were checked for agreement with the availible medications. They were in agreement. 2 clients PI were checked for agreement with availible monies. they were in agreement

The fire extinguisher is dated mar 2025., the smoke/co alarm is functional. first aid kit has necessary items

5 of 5 client files were reviewed, including but not limited to ipps, signed admission agreements, valubles, predadmission appraisal, and 602's. files present and up to date. administrator files were reviewed, including but not limited to facility license, administrator certificate, fire clearance, gaurdian clearance, infection control plan, and evacuation control plan. files are present and up to date. 5 of 9 staff files were reviewed, including but not limited to fingerprint/backround clearance, first aid/cpr, and ongoing training. files are present and up to date. 4 clients interviewed. 1 staff interviewed.

A copy of the report was read and given to the administrator, no citations issued at this time. an exit interview was conducted.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2025
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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