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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700627
Report Date: 12/29/2021
Date Signed: 12/29/2021 12:28:46 PM

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
12/28/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20211228135416
FACILITY NAME:G.L.O.M. A.R.F. 4FACILITY NUMBER:
392700627
ADMINISTRATOR:JESSICA OWENSFACILITY TYPE:
772
ADDRESS:8210 BRIGHT STREETTELEPHONE:
(209) 330-7155
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY:15CENSUS: 15DATE:
12/29/2021
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Jessica OwensTIME COMPLETED:
11:55 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient food supply for 2-day perishable and 7-day non perishable quantities
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12-29-21 at 10:05am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the complaint allegation noted above. LPA met with Administrator Jessica Owens and explained the purpose of the visit. LPA conducted facility observation of food storage areas and kitchen areas. LPA also reviewed menu dated 12-26-21 to 1-1-22. Based on observation food supply was adequate to meet the scheduled menu items. Perishable food items include but are not limited to: Milk, eggs, butter. Meat products were observed as well as canned foods and snacks for residents. Food items met the 2-day perishable and 7-day non-perishable food supply during observation. LPA also interviewed Staff1 (S1), S2, and S3, as well as Resident1 (R1), R2, and R3. At 11:50am on 12-29-21, LPA observed lunch meal service and observed all 15 residents eating menu items including vegetables and beverages, as well as snacks. Based on interviews, observations and record review, it is determined that facility is currently meeting the regulatory food supply. Therefore, this allegation is UNSUBSTANTIATED.

An exit interview was conducted with Jessica Owens and a copy of this report was left with Jessica.
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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