392700627-1-4-2022-27-AS-KHOS-CAKKFU-20220111065229

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700627
Report Date: 12/29/2021
Date Signed: 01/04/2022 10:39:55 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2021 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20211202135930

FACILITY NAME:	G.L.O.M. A.R.F. 4		FACILITY NUMBER:	392700627
ADMINISTRATOR:	JESSICA OWENS		FACILITY TYPE:	772
ADDRESS:	8210 BRIGHT STREET		TELEPHONE:	(209) 330-7155
CITY:	FRENCH CAMP	STATE: CA	ZIP CODE:	95231
CAPACITY:	15	CENSUS: 15	DATE:	12/29/2021
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Jessica Owens		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Staff failed to provide adequate food service
Facility is in disrepair
Licensee did not ensure that sufficient direct care staff are at the facility whenever clients are present

INVESTIGATION FINDINGS:

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On 12-29-21 at 11:55am, Licensing Program Analyst (LPA} Michael Bilger arrived unannounced to deliver complaint findings for the allegations listed above. LPA met with Jessica Owens and explained the purpose of the visit. During this investigation LPA interviewed three staff and three clients. LPA also conducted record reviews of facility menu, actual hours worked, staffing schedule, food/grocery receipts, food expense records, staffing roster, and resident roster. LPA also conducted facility observations on 12/3/21 and 12/22/21 to observe physical plant, functionality of items within facility, and food storage.
Allegation #1: Facility failed to provide adequate food service: LPA observed food storage at facility on 12-3-21 and 12-22-21, and reviewed food/grocery receipts dated 11-11-21, 11-19-21, 12-2-21, 12-7-21, and 12-22-21. LPA also reviewed facility’s menus for November and December of 2021. LPA also interviewed three staff members and three clients in care. Based on interviews and record reviews, it is determined that facility conducts shopping in 1–2-week intervals. LPA observed food on hand and food purchased to meet the requirements of adequate food supply. On 12-29-21 at 11:50am, LPA observed meal service to residents.
{Cont. on 9099C}

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20211202135930

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: G.L.O.M. A.R.F. 4	FACILITY NUMBER: 392700627
	VISIT DATE: 12/29/2021

NARRATIVE

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It was also determined that food supply on hand and food purchased matched the scheduled items on the facility menu. Interviews revealed adequate food is being distributed to clients in care at this time. Based on interviews, observation, and record review, it is determined that the preponderance of evidence standard is not met, therefore this allegation is UNSUBSTANTIATED.

Allegation #2: Facility is in disrepair: LPA conducted facility observation on 12-3-21 and 12-22-21. LPA toured facility inside and out and tested functionality of doors, bathroom faucets, toilets, and showers. LPA also observed common areas, resident bedrooms, and kitchen area. LPA also interviewed three staff and three clients in care. Based on observation and interviews, it is determined that facility toilets, faucets, and doors function properly. Facility was observed by LPA to be clean and sanitary with no foul odors. Facility also contained adequate lighting throughout. Interviews conducted revealed facility has an internal maintenance service to address any as needed repairs. LPA observed a completed maintenance log dated 10/31/21 to 12/24/21. Based on interviews and observations it is determined that the preponderance of evidence standard is not met, therefore this allegation is UNSUBSTANTIATED.

Allegation #3: Licensee did not ensure that sufficient direct care staff are at the facility whenever clients are present. LPA conducted interviews with three staff members and three residents. LPA also reviewed facility staffing schedule and actual hours worked. Based on interviews and record reviews it is determined that facility maintains 4 staff on during AM shift, 4 staff on during PM shift, and 2 staff on during night shift. LPA also observed staffing levels consistent with staffing schedules. Interviews revealed clients’ needs are met based on current staffing levels. Based on observations, interviews, and record reviews, it is determined that the preponderance of evidence standard is not met, therefore this allegation is UNSUBSTANTIATED.

Based on this investigation and today’s visit, no deficiencies are cited. An exit interview was conducted with Jessica Owens and a copy of this report was left with Jessica.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021

LIC9099 (FAS) - (06/04)

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