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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 06/14/2024
Date Signed: 06/14/2024 11:14:28 AM

Document Has Been Signed on 06/14/2024 11:14 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:G.L.O.M. A.R.F. 4FACILITY NUMBER:
392700627
ADMINISTRATOR/
DIRECTOR:		JESSICA OWENSFACILITY TYPE:
772
ADDRESS:8210 BRIGHT STREETTELEPHONE:
(209) 330-7155
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY: 15CENSUS: DATE:
06/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Barbara PiggeeTIME VISIT/
INSPECTION COMPLETED:
11:14 AM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 06/14/2024 at 11:00 AM to conduct a case management visit. LPA Martinez met with Barbara Piggee and explained the purpose of the visit.

The purpose of today's visit is to follow up on care and supervision. It was learned clients were receiving care and supervision and other community services at an unlicensed care facility. As a result, the facility is not following the approved plan of operation that was submitted to the Community Care Licensing Department (CCLD). Any significant changes in the plan of operation which would affect the services to clients shall be submitted to the licensing agency for approval. Therefore, the facility Licensee will need to submit an updated plan of operation to CCLD if clients will return to any G.L.O.M community center. Updated plan of operation has been submitted to CCLD. As a result, deficiencies have been cited for not following plan of operation. In addition to, administrator qualification due to not conforming to the applicable laws, rules and regulations.

As a result of this visit, the following deficiencies were cited, per Title 22 Regulations. Deficiencies can be found on the 809-D page. An exit interview was conducted, and a copy of this 809 report, 809-D page, and appeals rights were provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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 06/14/2024 11:14 AM - It Cannot Be Edited


Created By: Avelina Martinez On 06/14/2024 at 10:30 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
, 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: 06/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2024
Section Cited
CCR
87208(a)

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87208(a) Plan of Operation: Each facility shall have and maintain a current, written definitive plan of operation... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval...This requirement was not met as evidence by:
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Facility has provided CCLD an updated plan of operation.
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Based on visit inspections, file review, and interviews, the Licensee did not ensure that the CCLD approved plan of operation was being followed, and/or did not submit an updated plan of op to CCLD for significant changes that affected the services to clients. This posed a potential health and safety risk to clients.
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Type B
06/28/2024
Section Cited
CCR87405(d)(2)

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87405(d)(2) Administrator Qualifications & Duties: The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidence by:
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 Completed POC and reviewed Title 22 Regulations...87405 and 87208 Confirmation of review email was emailed to LPA Martinez.
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based on file reviews and interviews. The Administrator did not ensure to conform to Title 22 Regulations and did not implement plan of operation Title 22 regulations. This posed 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:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024


LIC809 (FAS) - (06/04)
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