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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700628
Report Date: 08/26/2022
Date Signed: 08/26/2022 12:28:24 PM

Document Has Been Signed on 08/26/2022 12:28 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Fanesha CaldwellTIME COMPLETED:
12:45 PM
NARRATIVE
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On 8/26/22 at 10:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to continue a complaint investigation. 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.

During the course of the visit LPA Jensen determined that staff 1 (S1) and staff 2 (S2) were not associated to the facility as required by Criminal Record Clearance regulation. As a result a $500 civil penalty is being issued on this day.

An exit interview was conducted a copy of this report with appeal rights were given 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
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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Document Has Been Signed on 08/26/2022 12:28 PM - It Cannot Be Edited


Created By: Maja Jensen On 08/26/2022 at 11:52 AM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: G.L.O.M. A.R.F. 5
FACILITY NUMBER: 392700628

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2022
Section Cited
CCR
81019(e)(2)

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...All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility:
...(2) Request a transfer of a criminal record clearance ...
This requirement was not met as evidenced by:
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Licensee agrees to associate S1 by the Plan of Correction due date and email LPA Jensen at maja.jensen@dss.ca.gov once complete so that the LPA may verify the association has been formed.
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Based on LPA Jensen's observation of S1 working at the facility and LPA Jensen's verification that S1 is not associated with the facility as verified in Guardian.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Maja Jensen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022


LIC809 (FAS) - (06/04)
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