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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700629
Report Date: 10/18/2021
Date Signed: 10/18/2021 02:41:17 PM

Document Has Been Signed on 10/18/2021 02:41 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: 10DATE:
10/18/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Director Peggy PhelpsTIME COMPLETED:
03:00 PM
NARRATIVE
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On 10/18/2021 Licensing Program Analyst (LPA), Jason Lund conducted an unannounced case management visit to follow up on documents that had previously been requested and unfulfilled. At approximately 2:15 PM, LPA Lund met with Director, Peggy Phelps and discussed the purpose of the visit.

Based on information provided, on 09/23/2021 the Regional Manager (RM) requested documentation showing the name of the acting CEO and the names of the Board of Directors. The RM further requested that if the Board does not appoint and provide a CEO, all board members will need a background clearance as the Board is considered as having operational control. These documents were to be submitted to the RO by COB Monday, September 27, 2021. An extension was granted to provide the requested documents by 10/04/2021. On 10/06/2021, and 10/12/2021 the RM followed up via email as a result of the requested documents not being provided. Documents to be provided are the LIC 200 and LIC 308 for each facility that is currently licensed, signed by the CEO or acting CEO designated by the Board. In addition, CCLD requested the names and titles of board members. If the board does not appoint and provide a CEO, all board members will need a background check as the Board is considered as having operational control. To date, CCLD has not received the requested documents.

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

Exit interview conducted with Director Peggy Phelps. A copy of report and Appeal Rights given
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
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 10/18/2021 02:41 PM - It Cannot Be Edited


Created By: Jason Lund On 10/18/2021 at 02:07 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. 3
FACILITY NUMBER: 392700629

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2021
Section Cited
CCR
80061

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80061-Reporting Requirements
Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.and (e) The items below shall be reported to the licensing agency within 10 working days following the occurrence.
(1) The organizational changes specified in Section 80034(a)(2).
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The facility will turn required papperwork, by 10/29/2021
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This requirement is not met as evidenced the facility has not turned Documents to be provided are the LIC 200 and LIC 308 for each facility that is currently licensed, signed by the CEO or acting CEO designated by the Board. This poses a potential 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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2021


LIC809 (FAS) - (06/04)
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