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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700627
Report Date: NO Visit Data Available
Date Signed: 01/02/2024 11:14:25 AM

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
and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230926165820
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:
UNANNOUNCEDTIME BEGAN:
MET WITH:Alex Archangel TIME COMPLETED:
ALLEGATION(S):
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Licensee is not ensuring that residents in care are provided with a sufficient amount of food.
Licensee is not ensuring that residents in care are provided with sanitary drinking water.
INVESTIGATION FINDINGS:
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On 12/12/2023 Licensing Program Analyst (LPA) LPA Martinez arrived at the facility unannounced at 9:15 AM. LPA Martinez arrived at the facility to amend LPA Jennifer Fain's 11/21/2023 complaint report. LPA Martinez amended the 11/21/2023 report, so it reflects public. In addition, the two 11/21/2023 deficiency pages can be found this 9099 report. LPA Martinez met with Alex Archangel on 12/12/2023 to explain the purpose of this visit. The 11/21/2023 report and deficiency pages can be found below.

On 11/21/23 at approximately 9:30am Licensing Program Analyst (LPA) Jennifer Fain arrived unannounced to deliver findings for a complaint investigation into the above listed allegations. LPA met with Joe Navarro and explained the purpose of the visit. Staff informed LPA that a resident had recently tested positive for Covid but tested negative on 11/20/23.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

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

DATE:
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 5
Control Number 27-AS-20230926165820
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: 12/12/2023
NARRATIVE
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Allegation #1
Licensee is not ensuring that residents in care are provided with a sufficient amount of food.
On 10/3/23 LPA Fain inspected the back kitchen, the front kitchen and the pantry to assess food supplies. Regional Program Manager (RPM) Alex Archangel gave LPA a copy of the Monthly menu. LPA checked food supply to ascertain if ingredients were available for the meals listed for Tuesday dinner through Thursday dinner (10/2/23 – 10/4/23.) Fruit, apples, celery sticks, coleslaw greens, brownie mix and ground beef were missing from the 7 meals and 8 snacks planned over that time period. RPM left the facility to shop for the required items. LPA observed sufficient food supplies to substitute other items if needed.

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On 11/3/23 LPA Lewis toured the kitchen area and reviewed the food supply. LPA Lewis found the food stores sufficient to ensure a 2-day perishable and 7 day non-perishable food supply was available.
On 11/21/23 LPA Fain observed breakfast and toured the facility kitchens and pantry. LPA observed breakfast. Residents were served eggs, turkey sausage, and fried potatoes. Missing from the posted menu were mushrooms, onions, and bell peppers. LPA observed there was no fresh fruit at the facility. LPA interviewed 5 of 12 residents. All residents interviewed stated they were served enough food.
Based on LPAs’ observations and interviews which were conducted, The facility did not have the required fruits and vegetables on 2 of 3 visits. Facility did not serve the vegetables with the meal as planned on the menu on 1 of 3 visits. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Allegation #2

Licensee is not ensuring that residents in care are provided with sanitary drinking water.

On 10/13/23 Regional Office (RO) received by email a water test dated 10/10/23 conducted by Denele Analytical, Inc. The test only listed nitrate concentration. It did not specify a location of where the water was drawn from nor if the water was safe to drink. LPA Fain requested the missing information from RPM.

Continued...

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230926165820
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: 12/12/2023
NARRATIVE
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On 11/14/23 (RO) received, by email, water test results from ETR Laboratories. The sample was taken by Jeff Larsen at 10:30:00 AM on 8/28/2023. Point of collection: Well Pump Test 'T". Results were dated 9/1/2023. Results supplied contaminants tested for and the levels detected. The results did not state if the water was safe for drinking.

On 11/17/23 RO received an email from the San Joaquin County Environmental Health Department stating, “… the nitrate level alone is enough to conclusively determine that the water does not meet water quality standards for drinking. The nitrate level is significantly above the Maximum Contaminant Level, so that … requires an immediate Do Not Drink notice…”

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On 11/21/23 LPA Fain spoke with RPM by phone. RPM stated the test performed on 10/10/23 conducted by Denele Analytical showed the corrections made based on the results from the test performed on 9/1/23 by ETR Laboratories. LPA Fain noted it did not address the total bacteria count 645cfu/ml (limit 500cfu/ml), Manganese .24mg/l (limit .05mg/l), T.D.S. 1,213.2mg/l (limit 500mg/l), or chloride 606.58mg/l (limit 250mg/l). RPM stated the new test results should be available by 2pm, 11/21/23.

Based on LPA’s interviews and record review(s), including email from San Joaquin County Environmental Health Department, who reviewed the test results, stating, “…the water does not meet water quality standards for drinking,…” the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.


As a result of this investigation, citations are issued under Title 22, Division 6. Chapter 1. An exit interview was conducted with Joe Navarro and a copy of this report, 809D pages and Appeal Rights were provided to Joe Navarro.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230926165820
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: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2023
Section Cited
CCR
80021(b)(2)
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(b) All community care facilities where water for human consumption is from a private source shall meet the following requirements: (2) Subsequent to initial licensure, the licensee shall provide evidence of a bacteriological analysis of the private water supply as frequently as is necessary to ensure the safety of the clients. This requirement is not met as evidenced by:
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Licensee has installed a reverse osmosis treatment system. Nitrate content has been corrected. Licensee will send report regarding other contaminants that are over the limit by 11/22/23 to jennifer.fain@dss.ca.gov
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Based on water test results supplied by G.L.O.M. 4 and analyzed by San Joaquin County Environmental Health Department, the water from the well does not meet the standard for drinking. This poses an immediate health and safety 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: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20230926165820
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: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2023
Section Cited
CCR
80076(a)(1)
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(a) In facilities providing meals to clients, the following shall apply:(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily
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PD states shopping schedule for perishables will be changed from every two weeks to once a week. Receipts for weekly shopping will be emailed to Liza.King@dss.ca.gov
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Food Guide for the age group served. This requirement is not met as evidenced by:Based on observation and interview the facility did not ensure that residents were receiving 1/3 of their daily requirement of fruits and vegetables at each meal. This poses a potential health and safety risk to residents in care.
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Type B
11/28/2023
Section Cited
CCR
80061(b)(1)(E)
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(b) Upon the occurrence, during the operation of the facility, of any of the events specified in 1, below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours… (1) Events reported shall include the following:
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Licensee states she will read the regulation and provide an attestation that she understands and will follow it.
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(E) Any unusual incident … which threatens the physical or emotional health or safety of any client. This requirement is not met as evidenced by:Licensee did not ensure the well water test which found unsafe drinking water at the facility was reported to CCLD. This poses a potential health and safety 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: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5