392700629-6-16-2025-27-AS-NWPN-DHPUJP-20250616153752

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700629
Report Date: 06/16/2025
Date Signed: 06/16/2025 03:38:07 PM

Document Has Been Signed on 06/16/2025 03:38 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. 3		FACILITY NUMBER:	392700629
ADMINISTRATOR/ DIRECTOR:	ALEXANDRA ARCHANGEL		FACILITY TYPE:	772
ADDRESS:	1117 SOUTH GRANT STREET		TELEPHONE:	(209) 330-7155
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 15		CENSUS: 13	DATE:	06/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Alexandria Archangel		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/16/25 at 9:00am Licensing Program Analyst (LPA) Noel Wolf Petersen arrived unannounced and met with Alexandria Archangel to explain the purpose of the visit; to conduct an annual inspection. GLOM3 is a Social Rehabilitation facility licensed for 15, the current census is 13. There is 13 amublatory resident(s), 0 nonambulatory resident(s), and 0 bedridden residents. Physical plant was inspected, included but not limited to the hallways, storage areas, client bedrooms, client bedrooms, common areas, exterior, and evacuation routes. The facility is clean and traffic areas are well lit and unobstructed. Sharps, Toxics, and Medications are in locked storage. There is 2 days of perishable and 7 days of non perishable food, the menu reflects what is available and alternate choices. The clients water temperature was measured at 109*F. The fire extinguisher was dated 1/30/25. Required posters were of the correct size and dimension. The first aid kit had the required items. Trash cans had required coverings. Phone and internet use was private, internet use was not reasonably accessible. Bedding was encased to prevent bugs. Continued on C page

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 06/16/2025

NARRATIVE

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Client records were inspected, including but not limited to admission agreements, needs and services plans, and 603s; these documents are up to date and present. Care observed matches the needs and services plans. 2 clients were interviewed.

5 Staff records were inspected, including but not limited to, Criminal backround checks, required trainings, and first aid certification; these documents are up to date and present. 2 staff were interviewed.

The administrator records were inspected, including but not limited to; proof of control of the property, liablity insurance, facility sketch, fire drill record, evacuation plan, infection control plan and the administrator certificate. Dues are paid.

Per title 22, citation(s) were issued on following D Pages

A copy of the report was read and left for the administrator. Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/16/2025 03:38 PM - It Cannot Be Edited

Created By: Noel Wolf Petersen On 06/16/2025 at 03:28 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: G.L.O.M. A.R.F. 3	FACILITY NUMBER: 392700629
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1537.1(b)(2)

Regulations

(b) A licensee shall ensure the following requirements are met in providing any internet access device for client use: (2) The device shall be made available to clients in a manner that permits shared access among all clients in the facility during reasonable hours. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above in the device being not reasonably accessible by virtue of being locked in a cabinent which had no spare key, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2025
	Plan of Correction
1 2 3 4	Provide the LPA with a picture of a posted sign delaring avalible private teleconfrences for the clients to use, and a picture of the device.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Liza King
NAME OF LICENSING PROGRAM MANAGER:

	Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/16/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2025

LIC809 (FAS) - (06/04)

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