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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700629
Report Date: 01/06/2022
Date Signed: 01/13/2022 05:00:11 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
12/22/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211222092516
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: DATE:
01/06/2022
UNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:K EdmondsTIME COMPLETED:
03:39 PM
ALLEGATION(S):
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Facility does not meet residents' nutritional needs
Staff do not wear masks
INVESTIGATION FINDINGS:
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Allegation: Facility does not meet residents' nutritional needs.
Based on LPA's observation it appears that the food supply is insufficient and does not meet the scheduled menu items. LPA White observed no milk or eggs during visit on 1/4/2022, LPA White also observed 11 pieces of fruit on that day. LPA White observed insufficient canned goods and meat products on that visit as well. LPA White interviewed 4 staff members on 1/4/2022. 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 White observed food items do not meet the 2-day perishable and 7 day non-perishable food supply during observation. LPA Johnson also confirmed that the facility is preparing food 2 days in advance and that the food storage is questionable based on the lack of documentation for temperatures checked of the refrigerator and freezer for the month of December 2021 and January 2022. The last temperature check was on December 5th of 2021. Continued>
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
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 5
Control Number 27-AS-20211222092516
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: 01/06/2022
NARRATIVE
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Allegation: Staff do not wear masks. Based on observation and records reviewed the staff are not following the required mitigation plan to document temperatures, exposure etc.. as outlined in the facilities plan. Records reviewed on 12/27/2021 confirmed that there was missing documentation for Staff on 12/20/2021, 12/26/2021 and for 12/27/2021. LPA also discovered that staff will come to work without a mask and the facility does not have mask to support the staff with the required Personal Protection Equipment (PPE). Staff will have to go and purchase their own PPE. The facility failed to protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that facility staff did not document Covid -19 screening questionnaire on multiple occurrences.


Based on LPA's observation, records reviewed and interviews which were conducted, 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
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20211222092516
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: 01/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2022
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: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20211222092516
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: 01/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2022
Section Cited
HSC
1550(C)
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ยง1550 Licenses or administrator Certificates; suspension, revocation or denial of application; grounds (c) Conduct which is inimical to the health, morals, welfare, or safety of either
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Licensee will conduct a training on the facilities mitigation plan, PPE guidance, documentation and provide proof to LPA by POC due date of 1/07/2021. If additional time is need please submit a request for extension by POC date.
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the people of this state or an individual in, or receiving services from, the facility or certified family home.This requirement was not met as evidence by records reviewed and interviews conducted facility staff did not document Covid -19 screening questionnaire on multiple occurrences. This is an immediate health and safety risk to residents 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: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
12/22/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211222092516

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: DATE:
01/06/2022
UNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:K EdmondsTIME COMPLETED:
03:39 PM
ALLEGATION(S):
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Staff do not sanitize facility
INVESTIGATION FINDINGS:
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Based on records reviewed and interviews with staff, The department is unable to determine if staff are sanitizing the facility on all shifts. The facility provide the department with a cleaning schedule for each shift. The facility also has posted information about cleaning and sanitizing the facility as well as the resident reminders to wash their hands.

LPA observed a clean facility on the visits that were conducted on multiple days and also observed cleaning supplies avaiiable for staff to use. The information provided for this investigation by the facility addresses the requirements for compliance with the department.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5