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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 10/18/2021
Date Signed: 10/19/2021 07:39:51 AM

Document Has Been Signed on 10/19/2021 07:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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. 4FACILITY NUMBER:
392700627
ADMINISTRATOR:JESSICA OWENSFACILITY TYPE:
772
ADDRESS:8210 BRIGHT STREETTELEPHONE:
(209) 330-7155
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY: 15CENSUS: DATE:
10/18/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Jessica Owens, AdministratorTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bruce Jacobs conducted an unannounced case management visit to follow up on documents that had previously been requested and not received by the Department., LPA met with Executive Director Jessica Owens and discussed the purpose of the visit.

Based on information provided, on 09/23/2021 the Licensing Regional Manager (RM) requested documentation showing the name of the acting CEO and the names of the Board of Directors. The RM further requested that if the Board does not appoint and provide a CEO, all board members will need a background clearance as the Board is considered as having operational control. These documents were to be submitted to the RO by COB Monday, September 27, 2021. An extension was granted to provide the requested documents by 10/04/2021. On 10/06/2021 and 10/12/2021, the RM followed up via email as a result of the requested documents not being provided. Documents to be provided are the LIC 200 and LIC 308 for each facility that is currently licensed, signed by the CEO or acting CEO designated by the Board. In addition, CCLD requested has requested the names and titles of board members. If the board does not appoint and provide a CEO, all board members will need a background check as the Board is considered as having operational control. To date, CCLD has not received the requested documents.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Executive Director. A copy of report and Appeal Rights given
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2021 07:39 AM - It Cannot Be Edited


Created By: Bruce Jacobs On 10/18/2021 at 05:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2021
Section Cited
CCR
80061(a)&(e)

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Reporting Requirements a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section (e) The items below shall be reported to the licensing agency within 10 working days of the following occurrences (1) The organizational changes specified in
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Plan of Correction: Facility will submit a LIC 200. LIC 308. LIC 309 and Board Resolution appointing a new CEO. aLLBoard Members are to submit a background check to the Department if a new CEO is not appinted by the POC due date

POC due date is 11/01/21 . (10 days).
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Section 80034(a)(2). This requirement was not met as evidenced by: Requested documentation for a change in the CEO was requested by the Department on 9/23/21 and the documents have not been received.

This poses a potential Health and Safety risk to clients 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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2021


LIC809 (FAS) - (06/04)
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