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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 02:30:50 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
11/12/2021 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211112102408
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:
12:40 PM
MET WITH:Jessica Owens, AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident was physically abused.
Staff member threatened client.
Staff member made an inappropriate comment to client.
INVESTIGATION FINDINGS:
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On 01/06/2022, Licensing Program Analyst (LPA) T. White conducted an unannounced complaint investigation regarding the above allegations. LPA White discussed the purpose of the visit and the elements of the allegations with Administrator, Jessica Owens.

During the course of investigation, LPA White interviewed 4 Staff Members and 4 clients. LPA received the following documents for Client #1 (C1): Physician Report (LIC602), Identification and Emergency Information, Needs and Service Plan, and Incident Report.

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-20211112102408
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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Resident was physically abused.
LPA interviewed 4 clients and 4 staff members. Based on interview, complainant stated staff hit her in the nose and obtained a black eye. Based on client interviews, 4 of 4 clients stated staff has not physically abused clients. Based on staff interviews, 4 of 4 staff members stated staff has not physically abused clients at the facility. However, Staff #1 (S1) and Staff #4 (S4) observed C1 obtained a black eye. S1 and S4 both stated when staff asked C1 about blackeye, C1 had multiple different stories.

Staff member threatened client.
LPA interviewed 4 clients and 4 staff members. Based on interview, complainant stated staff did not threaten her or other clients. Based on client interviews, 4 of 4 clients stated staff do not threaten clients. Based on staff interviews, 4 of 4 staff members stated staff has not threatened any clients at the facility. However, LPA is unable to prove or disapprove if allegation occurred.

Staff member made an inappropriate comment to client.
Based on interview, complainant stated staff member made inappropriate comments to client. Based on client interviews, 4 of 4 clients stated staff has not made any inappropriate comments to clients. Based on staff interviews, 4 of 4 staff members stated staff does not make inappropriate comments to clients. However, LPA is unable to prove or disapprove if allegation occurred.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited during visit.



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