392700627-12-19-2024-27-AS-KHOS-DD6JK6-20250122060636

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700627
Report Date: 12/19/2024
Date Signed: 12/19/2024 06:55:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/15/2024 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20241015104658

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:	12/19/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator Jessica Owens		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff do not ensure residents have access to hot water

Staff do not ensure residents have access to a working telephone

Staff do not serve an adequate amount of fruits and or vegetables

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to complete a complaint investigation regarding the above allegations. LPA Lund met with Administrator Jessica Owens. and explained the reason for the visit. Census: 15
Staff do not ensure residents have access to hot water - LPA Lund reviewed facility records, interviewed staff, reporting party and clients in care. Based on records reviewed, interviews with staff, reporting party, and clients in care. The facility had did have a hot water issue and had Accuflow Pumbing, Inc come out on 10/1/2024, 10/15/2024 and 10/16/2024 to fix the hot water. Staff interviewed stated that clients told them the water was warm engough to take a shower. Clients in care interviewed stated the hot water was warm for a couple of days until the facility fixed it. They had enough water to take a shower.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

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-20241015104658

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: G.L.O.M. A.R.F. 4	FACILITY NUMBER: 392700627
	VISIT DATE: 12/19/2024

NARRATIVE

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Based on records reviewed, interviews with staff, reporting party and residents in care, on the information provided, it was unclear if staff do not ensure residents have access to hot water, therefore the allegation was deemed UNSUBSTANTIATED.

Staff do not ensure residents have access to a working telephone - LPA Lund observed the phone to be working, interviewed staff, clients in care and reporting party. On 10/16/2024, 11/8/2024 and 12/11/2024 LPA Lund observed the clients using the phone. LPA interviewed clients in care who stated the phone worked but had static noise sometimes. Staff interviewed stated no clients in care approached staff stating the phone didn’t work.

Based on LPA’s observation, interviews with staff, clients in care and reporting party, on the information provided, it was unclear if staff do not ensure residents have access to a working telephone, therefore the allegation was deemed UNSUBSTANTIATED.

Staff do not serve an adequate amount of fruits and or vegetables – LPA’s reviewed facility records, observed, interviewed staff, clients in care and reporting party. On 5/10/2024, 10/16/2024 and 12/17/2024 LPA’s observed in excess of a two- day supply of perishable food and a 7- day supply of non-perishable food. That included sufficient amounts of fruits and or vegetables. LPA Lund reviewed four weeks of G.L.O.M #4 menu for Breakfast, Lunch, Dinner and Snacks. Staff interviewed stated that the clients in care get sufficient amount of food. Clients interviewed stated that the receive sufficient amount of food including fruits and vegetables.

Based on reviewed facility records, interviewed staff, and reporting party, on the information provided, it was unclear if staff do not serve an adequate amount of fruits and or vegetables, therefore the allegation was deemed UNSUBSTANTIATED.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and report left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC9099 (FAS) - (06/04)

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