392700628-5-23-2025-27-AS-NWPN-DGXVZV-20250523165322

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700628
Report Date: 05/23/2025
Date Signed: 05/23/2025 04:53:46 PM

Document Has Been Signed on 05/23/2025 04:53 PM - 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. 5		FACILITY NUMBER:	392700628
ADMINISTRATOR/ DIRECTOR:	JESSICA OWENS		FACILITY TYPE:	772
ADDRESS:	458 ALMOND DRIVE		TELEPHONE:	(209) 330-7155
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY: 16		CENSUS: 14	DATE:	05/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:49 PM
MET WITH:	Jessica Gutierrez		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/23/25 at 12:45 Licensing Program Analyst (LPA) Noel Wolf Petersen and Licensing Program Manager (LPM) Liza King arrived unannounced to conduct an annual inspection. They were met by Staff Estaban Herrera and Administrator Jessica Gutierrez, and explained the purpose of the visit. G.L.O. M. 5 is a 16 bed facility for ambulatory adults with mental health diagnosis. The Physical plant was toured including the kitchen, common areas, resident bedrooms, resident bathrooms, hallways, evacuation routes, storage, and exterior. The Physical plant was sanitary, the traffic areas are unobscured and well lit. sharps and toxics and medications are locked away. The fire extinguishers were last inspected 5/1/25, The water temperature was measured at 111.1*F. The air temperature was comfortable. The smoke alarm and CO detectors were functional. The medication was observed for 3 residents at random. It was current and up-to-date with the MAR, 3 client files were reviewed, they included required signed admission agreements, assessment documentation, personal rights notifications, and emergency contact forms. 3 of 3 residents were able to leave facility unassisted and care for own personal needs. 3 staff files were reviewed, they included required fingerprinting/backround check and ongoing training documents. 1 of 3 staff files reviewed were not associated to the facility, however they were fingerprint cleared and associated to a sister facility, and the administrator addressed it before the LPA left. Staff trainings were reviewed, and found to have no concerns. cont. on C page

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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. 5	FACILITY NUMBER: 392700628
	VISIT DATE: 05/23/2025

NARRATIVE

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Administration files were reviewed, including but not limited to, the infection control plan, the evacuation plan and fire drills with no concerns.

Personal Rights:
*The facility phone is not possible to take private phone calls the plan of operation should have a provision that clients come with the capacity to use there own phone. There is only one phone in the facility.
*Additionally, LPM observed a "smoke break" in which a staff gathers cigarettes and a lighter in a locked area and took residents to the designated area to smoke. Interview with the Admin occured and it was explained that the facility has set smoking breaks, however, residents are able to ask to smoke anytime and staff will assist them.
Guidance was provided that this could be a personal rights violation if at anytime residents are not allowed to freely smoke or use a phone in private.
* Camaras were observed in common areas and removed during the visit. Interview with the Administrator whom reported that the video surveillance is inoperable. The admissions agreement did not contain consent for video surveillance nor does the Plan of Operation.
* The clients have no access to the internet.

Fire drill record was reviewed and appears to be occurring on multiple shifts each month. Recommendations are to test the system when conducting drills as often as possible.

The facility is encouraged to use nontoxic soap if bottles of soap are located in the bathroom, otherwise wall hanging soap may prevent ingesting the soap or using it for other means.

The facility has a work order for a broken toilet stop they addressed the broken toilet with a temporary stop.

Required furniture incl Night stands and bed coverings were reset during visit to meet requirements.

As per Title 22 regulations, deficiencies were cited on following D. Page.

An exit interview was conducted and a copy was read and left with the administrator.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2025 04:53 PM - It Cannot Be Edited

Created By: Noel Wolf Petersen On 05/23/2025 at 03:38 PM

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. 5	FACILITY NUMBER: 392700628
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

81072(a)(19)

81072 (a) (19) PERSONAL RIGHTS: Each client shall have personal rights which include, but are not limited to, the following: to have access to telephones in order to make and receive confidential calls, provided that such calls do not infringe upon the rights of other clients and do not restrict availability of the telephone during emergencies. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 0 objects which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2025
	Plan of Correction
1 2 3 4	There is a sign thats going to be posted designating the phone rules, a picture of the posted sign will get sent to the LPA by the plan of correction date 6/03/25.

Type B

Section Cited

HSC

1537.1(b)(2)

1537.1(b) (2) - Standard (b) A licensee shall ensure the following requirements are met in providing any internet access device for client use: (2) The device shall be made available to clients in a manner that permits shared access among all clients in the facility during reasonable hours. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview,the licensee did not comply with the section cited above in 1 out 1 devices which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2025
	Plan of Correction
1 2 3 4	The licensee will purchase a device, make the internet availible, send your receipt, and a picture of the signage designating its availibility of its use, to the LPA by the correction date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/23/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

LIC809 (FAS) - (06/04)

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