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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700627
Report Date: 07/28/2025
Date Signed: 07/28/2025 03:52:47 PM

Substantiated


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
07/24/2025 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20250724154805
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:
07/28/2025
UNANNOUNCEDTIME BEGAN:
02:18 PM
MET WITH:Casey KwokTIME COMPLETED:
02:19 PM
ALLEGATION(S):
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Staff do not maintain a comfortable temperature for clients in care
INVESTIGATION FINDINGS:
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On 7/28/25 at 2:00, Licensing Program Analyst(LPA) Noel Wolf Petersen arrived unannounced to conduct a complaint investigation and met with Administrator Casey Kwok, to explain the purpose of the visit.

The above allegation was Investigated by interview and record review. The LPA observed the temperature to be adequately cold in the affected part of the house at the time of the vist. The administrator provided that they put in a work order and there was a delay of roughly 11 days to fix one of the three AC's, and in that time they made a suggestion to upper management that fans should be provided to allievate the clients which were ultimately not provided. The effect of the interior temperature of that period was recollected by the clients as one client of 3 interviewed having trouble sleeping due to the heat, all three expressed concerns about general discomfort due the heat during the 11 day period. One resident partook of a relief offered by the facility to sleep in the common area with the functional AC unit.

Continued on C Page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
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-20250724154805
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: 07/28/2025
NARRATIVE
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The LPA offered guidance that the work order provided had a due date some month and a half out from the start date, which given the risk of heat exaustion and heat stroke and dehydration concerns related to psychtropic medications the residents are taking is an unreasonable timeline maximum for mid july. Alternative methods of providing safe comfortable accomodations, like providing fans when the AC is broken like the administrator suggested, should be pursued as an immediate remedy for discomfort.

Citation issued on following d page, appeal rights provided. An exit interview was conducted and a report was read and given to the administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250724154805
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2025
Section Cited
CCR
81087(a)(1)
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81087 BUILDINGS AND GROUNDS 81087 (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by:
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No Poc, The AC is fixed now.
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interview and record review where the AC was in a state of disrepair for a period of time(11 days)

which poses a threat to the saftey, welfare, and violiates the client rights of those 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: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3