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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700628
Report Date: 05/16/2022
Date Signed: 05/24/2022 09:45:29 AM

Document Has Been Signed on 05/24/2022 09:45 AM - 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:
(925) 570-3282
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 16CENSUS: 14DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Fanesha CaldwellTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) R. Campbell and T. White conducted an unannounced Annual 1-Year Required visit on this date. LPAs met and toured with Facility Manager, Fanesha Caldwell. The administrator, Jessica Owens currently holds a certificate (#6055006735) that expires on 01/07/2024.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 69 degree Fahrenheit. LPAs observed lighting in all rooms is adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 114 degree for the men's bathroom and 118 degrees Fahrenheit for the women's bathroom. All toilets, hand washing, and bathing areas are safe, sanitary and in operating condition. The supply of extra hygiene was available for clients. There is a minimum of 7-days of non-perishable foods and 2-days of perishable foods.

Smoke detector was interconnected with the fire department. Carbon monoxide alarm was in operating condition during inspection. Fire extinguisher was last serviced on January 10, 2022. Emergency Disaster Plan was last posted on 03/18/2022. First aid kit was observed to be complete with manual, tweezers and scissors. Fire drill was last conducted on 03/20/2022.
LPAs reviewed four staff record files and four client files.

LPAs observed the following deficiency:
- During record review, LPAs observed, Staff #4 (S4) was cleared but not associated to the facility.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 ,and California Health and Safety Code. Failure to correct deficiency may result in civil penalties.

Exit interview conducted with Facility Manager. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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 05/24/2022 09:45 AM - It Cannot Be Edited


Created By: Renee Campbell On 05/16/2022 at 01:17 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
, 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: 05/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
81019(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 81019(f); or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on documentation, the facility did not comply with the section cited above in 81019 (e) (2). LPAs observed S4 was cleared but not associated with the facility. This poses an immediate health and safety risk to clients in care.

POC Due Date: 05/17/2022
Plan of Correction
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Facility manager agreed to associate S4 to the facility and submit proof to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2022


LIC809 (FAS) - (06/04)
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