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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 12/09/2022
Date Signed: 12/09/2022 04:01:52 PM

Document Has Been Signed on 12/09/2022 04:01 PM - 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: 15DATE:
12/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Karen EdmondTIME COMPLETED:
04:15 PM
NARRATIVE
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On 12/9/22 at 2:30pm Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management on reporting requirements. LPA Jensen met with Facility Manager Karen Edmond and explained the purpose of today's visit.

On 12/9/22 LPA Jensen went to the San Joaquin County Sheriff's Department located at 7000 Michael Canlis Blvd. LPA Jensen was given records for incident report # 22-20057. The incident report was taken to document an altercation on 9/17/22. LPA Jensen was also provided call logs for an additional 3 reports that have not yet been finalized, for the following dates: 8/7/22, 10/26/22 and 10/27/22. These reports were not received by Community Care Licensing.

In addition, on 9/20/22, LPA Jensen was advised by a facility staff member that the facility had at least one known case of lice on that date. Upon learning of the infestation, LPA Jensen spoke to Alex Archangel and advised that an incident report will be required to document the case of lice. This report was not received by the Community Care Licensing.

Deficiencies are being cited for violations of the California Code of Regulations (CCR), Title 22, Division 6. Failure to correct deficiencies may result in the assessment of civil penalties.

An exit interview was conducted and a copy of this report and appeal rights were provided to facility manager.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/09/2022 04:01 PM - It Cannot Be Edited


Created By: Maja Jensen On 12/09/2022 at 03:46 PM
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: 12/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2022
Section Cited
CCR
80061(b)(1)(E)

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80061 Reporting Requirements

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. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event.

(1) Events reported shall include the following:
...
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by:
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Licensee agrees to fax and email all incidents listed in this LIC 809 to LPA Jensen by the Plan of Correction due date. Faxes will be sent to (916)263-4744 and emails will be sent to maja.jensen@dss.ca.gov. In addition, all incidents will be emailed to LPA Jensen with receipt effective immediately through 1/9/23.
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Based on LPA Jensen's review of law enforcement records referenced in the LIC 809 and verification that reports for these incidents were not received by Community Care Licensing. This poses a potential Health, Safety and Personal Rights Risk to resident 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:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022


LIC809 (FAS) - (06/04)
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