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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700629
Report Date: 06/17/2024
Date Signed: 07/24/2024 03:43:22 PM

Document Has Been Signed on 07/24/2024 03:43 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. 3FACILITY NUMBER:
392700629
ADMINISTRATOR/
DIRECTOR:		ALEXANDRA ARCHANGELFACILITY TYPE:
772
ADDRESS:1117 SOUTH GRANT STREETTELEPHONE:
(209) 330-7155
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 15CENSUS: 15DATE:
06/17/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Bruce Sheppard and Jake ReihhardtTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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A Non-Compliance Conference (NCC) was conducted today on June 17, 2024 via Microsoft Teams with the Sacramento South Regional Office. Present at today's meeting include the following: Community Care Licensing Department (CCLD) Regional Managers: Stephenie Doub and Brenda White; Licensing Program Managers: Liza King, Brenda Chan, and Harpreet Humpal; Licensing Program Analyst Avelina Martinez; DHCS: Whitney Hart, Kevin Ciacco, Maureen Cooper; BHS: Sabrina Parker and Cara Dunn; Facility Representatives: Jake Reinhardt, Bruce Sheppard, Nicole Bettencourt, and Lisa Evans; Also present: Manjit Kaur, Donna Bickham, Angel Adrian, and Delilah Garza.

The non-compliance conference process was explained during this meeting to include the Administrative process.

Issues/Concerns/other information discussed during the Non-Compliance Conference were:
  1. FINANCIAL AUDIT FOLLOW UP:
    • This audit is currently open, and further follow will be required. Audit finding will be provided/delivered to the Licensee at the completion of the Audit. Community Care Licensing Department (CCLD) will provide an Audit status update to facility representatives.
2. FLORA UNLICENSED complaint:
    • As of now there are no G.L.O.M clients at the Flora location. Care and supervision and SRF/DHCS services are being provided at Bright House, Almond facility, and Grant facility.
    • During this Conference, per Bruce Sheppard clients are always supervised by staff. In addition, Bruce Sheppard reported G.L.O.M clients will no longer will visit the Flora location.

    Continued...
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
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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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. 3
FACILITY NUMBER: 392700629
VISIT DATE: 06/17/2024
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  • DHCS Clarification regarding SRF: All services need to be completed at the SRF/residence. Telecare SRF related services should also be completed at the SRF/residence.
  • Community Outing Clarification: Community outing should be open to all members of the community. For example, a community outing will entail going to a mall or park...etc. A community outing would not be at a private day program or any other private location.

3. COMPLIANCE FOLLOW UP:
  • As of now, Oakland and Fresno regional offices did not have any concerns in regards to unlicensed care complaints or care and supervision at their licensed care facilities.
  • As of now, Sacramento regional office: did not have any concerns pertaining to annual inspections and the maintenance of G.L.O.M. facilities 3-4-5-6. (Concerns/Compliance is related to unlicensed complaints and financial audit, which information can be found on section 1-2)

The facility has stated they will do the following to achieve continued and substantial compliance:
  • Submit LIC 309 Administrative Organization form Community Care Licensing Department (CCLD)

Community Care Licensing Department (CCLD) will do the following:

  • Follow up on Financial Audit

Completing the Non-Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

Per California Code of Regulations (CCRs) - Title 22 no deficiencies are being cited at this visit. An exit interview was conducted with facility staff, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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