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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700628
Report Date: 05/09/2022
Date Signed: 05/09/2022 03:49:12 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
03/25/2022 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220325172152
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: 14DATE:
05/09/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jessica Owens, AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Facility does not have an adequate food supply for residents in care.
INVESTIGATION FINDINGS:
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On 05/09/2022 at 1:45 PM, Licensing Program Analyst (LPA) T. White arrived unannounced to 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 staff roster and menu's dated 03/2022 to 05/2022. On 03/30/2022, LPA observed adequate food supply in the pantry, refrigerator, and freezer. On 05/09/2022, LPA observed food supply was adequate and did meet the scheduled menu items. LPA observed refrigerator filled with milk, cheese, and vegetables. LPA observed 4 freezers filled with frozen meat and vegetables. LPA observed fruits, 7 day supply of non- perishables, and emergency supply located in the pantry.

LPA interviewed 5 staff members and 8 clients. 8 of 8 clients stated the facility provides adequate meals and snacks throughout the day. 5 of 5 staff members stated the facility ensures clients are provided adequate snacks and meals. However, LPA is unable to prove or disprove if allegation occurred.
Report continues on 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
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-20220325172152
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: 05/09/2022
NARRATIVE
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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. Document Link Icon
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2