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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700629
Report Date: 01/04/2022
Date Signed: 01/04/2022 12:12:36 PM

Substantiated


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
12/28/2021 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211228134110
FACILITY NAME:G.L.O.M. A.R.F. 3FACILITY NUMBER:
392700629
ADMINISTRATOR:ALEXANDRA ARCHANGELFACILITY TYPE:
772
ADDRESS:1117 SOUTH GRANT STREETTELEPHONE:
(925) 570-3282
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:15CENSUS: 12DATE:
01/04/2022
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Emily Beckwith, Program Director TIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Insufficient food supply for 2-day perishable and 7-day non perishable quantities
INVESTIGATION FINDINGS:
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On 01/04/2021 at 9:40am, Licensing Program Analyst (LPA) T. White arrived unannounced to open and investigate the complaint allegation noted above. LPA met with Program Director, Emily Beckwith and explained the purpose of the visit.

During course of investigation, LPA collected and reviewed staff roster and menues dated 01/04/2022 to 01/22/2022. LPA conducted facility observation of food storage areas and kitchen areas. LPA interviewed 4 staff members and 6 clients. 6 of 6 clients stated the facility provides adequate meals and snacks throughout the day. 4 of 4 staff stated the facility ensures clients are provided adequate snacks and meals.

Report continues on 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
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 3
Control Number 27-AS-20211228134110
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. 3
FACILITY NUMBER: 392700629
VISIT DATE: 01/04/2022
NARRATIVE
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Based on LPA observation, it appeared that the food supply was insufficient and did not meet the scheduled menu items. LPA observed no milk or eggs during visit. LPA observed 11 pieces of fruit. LPA observed insufficient canned goods and meat products. LPA interviewed 4 staff members. Based on interviews, 3 of 4 staff members stated there is insufficient food at this time. Staff #1 (S1) stated the facility will conduct grocery shopping today. Staff #2 (S2) stated there is insufficient food to meet the scheduled menu items. LPA observed food items do not meet the 2-day perishable and 7 day non-perishable food supply during observation.

Based on LPA's observation and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted with Program Director. A copy of this report and Appeal Rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20211228134110
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. 3
FACILITY NUMBER: 392700629
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/05/2022
Section Cited
CCR
85076(d)(1)
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85076(d)(1): Food Service: (d) The licensee shall meet the following food supply ...(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met as evidence by:
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Program Director agreed to conduct grocery shopping. Program Director will submit photos and receipt by POC date.
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Based on observation and interviews, the licensee did not comply with the section cited above in 85076(d)(1). LPA observed insufficient food supplies in the facility, which poses as a potential health and safety risks to clients in care
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3