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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700628
Report Date: 01/06/2022
Date Signed: 01/06/2022 02:16:57 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2021 and conducted by Evaluator Treana White
COMPLAINT CONTROL NUMBER: 27-AS-20211228135740
FACILITY NAME:G.L.O.M. A.R.F. 5FACILITY NUMBER:
392700628
ADMINISTRATOR:JESSICA OWENSFACILITY TYPE:
772
ADDRESS:458 ALMOND DRIVETELEPHONE:
(925) 570-3282
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:16CENSUS: 15DATE:
01/06/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Jessica Owens, Administrator TIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Insufficient food supply for 2-day perishable and 7-day non perishable quantities
INVESTIGATION FINDINGS:
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On 01/06/2022 at 9:40am, Licensing Program Analyst (LPA) T. White arrived unannounced to open and investigate the complaint allegation noted above. LPA met with Administrator, Jessica Owens and explained the purpose of the visit.

During course of investigation, LPA collected and reviewed menues dated 01/02/2022 to 01/22/2022. LPA conducted facility observation of food storage areas and kitchen areas. LPA interviewed 4 staff members and 6 clients. 5 of 6 clients stated the facility provides adequate meals and snacks throughout the day. 4 of 4 staff stated the facility ensures clients are provided adequate snacks and meals.

Report continues on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
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 2
Control Number 27-AS-20211228135740
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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. 5
FACILITY NUMBER: 392700628
VISIT DATE: 01/06/2022
NARRATIVE
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Based on observation, food supply was adequate to meet the scheduled menu items. Perishable food items included but not limited to: Milk, eggs, fruits, and vegetables. Sufficient meat products were observed as well as canned foods and snacks for clients. Food items met the 2-day perishable and 7-day non-perishable food supply during observation. However, 1 of 6 clients stated the facility does not provide adequate meals. Client #2 (C2) stated he is not always "full" from the meals provided.

Based on interviews, observations and record review, it is determined that facility is currently meeting the regulatory food supply. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.


An exit interview was conducted with Administrator and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2