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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 03/27/2023
Date Signed: 03/27/2023 02:23:57 PM

Document Has Been Signed on 03/27/2023 02:23 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:
03/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Karen EdmondTIME COMPLETED:
02:30 PM
NARRATIVE
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On 3/27/23 Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management in relation to program certification review completed on March 15, 2023 by the Department of Health Care Services (DHCS). LPAs Jensen and Fain met with site manager Karen Edmond and explained the purpose of today's visit. LPA Jensen also spoke to Lisa Owens, Program Director and explained the purpose of today's visit.

During the course of the on-site program certification review conducted on March 15, 2023, the DHCS determined the facility was out of compliance with the California Code of Regulations (CCR), Title 9, Section 532.1(b). Based on a review of 3 open client records, 2 of 3 records did not contain documented evidence that a screening for medical complications was conducted 30 days prior to or after admission.

LPA Jensen conducted an interview with Program Director Lisa Owens by telephone. The Program Director advised that on the same day the review by DHCS was conducted, a new process was implemented that has intake staff checking to verify a screening for medical complications has been conducted. As an additional measure, the assigned Administrator will also be verifying that the required screening has been conducted prior to admission. The 2 step verification process was immediately implemented and remains in effect at this time.

A deficiency is being cited from CCR, Title 22. 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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 03/27/2023 02:23 PM - It Cannot Be Edited


Created By: Maja Jensen On 03/27/2023 at 02:06 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: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2023
Section Cited
CCR
8000(b)

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General
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The licensee shall ensure compliance with all applicable law and regulation. This requirement was not met as evidenced by:
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The Licensee has implemented a process to have intake specialists verify that screening for medical complications has taken place prior to accepting a client for admission and as an additional measure the Administrator will also verify that the screening has taken place. The Licensee will email maja.jensen@dss.ca.gov confirmation that this protocol has been established by the Plan of Correction due date.
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Based on a review of 3 resident files, 2 of 3 files did not contained documentation serving as evidence that screening for medical complications had taken place. This poses a potential risk to the health, safety and personal rights of 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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
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