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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700628
Report Date: 08/26/2022
Date Signed: 09/22/2022 12:37:08 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
07/12/2022 and conducted by Evaluator Maja Jensen
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220712080944
FACILITY NAME:G.L.O.M. A.R.F. 5FACILITY NUMBER:
392700628
ADMINISTRATOR:JESSICA OWENSFACILITY TYPE:
772
ADDRESS:458 ALMOND DRIVETELEPHONE:
(209) 330-7155
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:16CENSUS: 12DATE:
08/26/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Fanesha CaldwellTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility rent has not been paid
Trash service has been interrupted
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/26/22 at 10:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation in to the above listed allegations. LPA Jensen met with Program Administrator Fanesha Caldwell and explained the purpose of today's visit. Regional Manager Alex Archangel joined the conversation by telephone.

Facility rent has not been paid
The complainant who reported that rent has not been paid has since recanted the allegation therefore the allegation is UNSUBSTANTIATED. A finding of unsubstantiated indicates that while the allegation may be true there is not a preponderance of evidence to prove a violation of regulation occured.

Trash service has been interrupted
During the course of the investigation LPA Jensen interviewed 3 staff members and 2 residents. All parties interviewed denied having knowledge of a trash service interruption. Continued on LIC 9099C....



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
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-20220712080944
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: 08/26/2022
NARRATIVE
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27
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32
Continued from LIC 9099....

Trash service has been interrupted
Based on the interviews conducted the allegation is UNSUBSTANTIATED. A finding of unsubstantiated indicates that while the allegation may be true there is not a preponderance of evidence to prove a violation of regulation occurred.

An exit interview was conducted and a copy of this report and appeal rights were provided to Program Administrator Fanesha Caldwell.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2