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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700627
Report Date: 09/22/2022
Date Signed: 09/22/2022 12:32:09 PM

Substantiated


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
07/28/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20220728100643
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: DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Alex Archangel-Program DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not properly supervise residents
INVESTIGATION FINDINGS:
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On 9/22/22 at 11:15am Licensing Program Analyst (LPA) Maja Jensen arrived at G.L.O.M. A.R.F. 5 unannounced to deliver findings for a complaint investigation in to teh above listed allegations. LPA Jensen met with Program Director Alex Archangel.

During the course of the investigation LPA Jensen interviewed 6 staff members and reviewed records including a staff roster with contact information, master staffing schedule, time sheets, San Joaquin Sheriff's Computer Aided Dispatch (CAD) call log. Based on a review of the time sheets it was determined that on multiple occassions there was only 2 staff at the facility. Based on interviews conducted the most recent dates with 2 staff working at the facility is 9/16/22 and 9/17/22. Based on time sheets reviewed, if 1 of the 2 staff members was on lunch or break there was only 1 staff member supervising clients. LPA Jensen confirmed through time sheets that scheduled hourly employees clocked out for lunch without exception.
Continued on LIC 9099C....

Continued on LIC 9099C....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20220728100643
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: 09/22/2022
NARRATIVE
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Continued from LIC 9099....
A review of the CAD call log shows that the sheriff's office responded 17 times to the facility in 2022. Police wrote incident reports for 6 of the 17 times they were called out to the facility. There are at least 5 reports of missing persons during the course of 2022. LPA Jensen received 5 of 6 Sheriff Office incident reports and is still pending receipt of 1 Sheriff Office incident report.

The allegation of staff did not supervise residents properly is SUBSTANTIATED. An finding of substantiated means that the preponderance of evidence standard has been met through records reviewed, staff interviews and the numerous occasions for which Sheriff's were required to respond to the facility.

Deficiencies are being cited from the California Code of Regulations, Title 22 Division 6.

An exit interview was conducted with Alex Archangel and a copy of this report and appeal rights were given to the program director, Alex Archangel.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220728100643
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2022
Section Cited
CCR
85065(b)
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85065 Personnel Requirements
(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. This requirement was not met as evidenced by:
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As proposed by facility Program Director, Licensee agrees to submit a plan by email to maja.jensen@dss.ca.gov by due date that will include actions taken to increase staffing levels and to conduct additional staff training.
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Based on the time sheets reviewed and interviews conducted there were multiple occasions during which only 2 staff members were present for a period of time at the facility with no coverage for rest periods. Additionally, based on the Sheriff's office needing to respond to the facility 17 times in less than 9 months with at least 5 incidents of resident AWOLs, staff did not supervise residents in care sufficiently to meet their level of need. This poses a potential health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3