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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700629
Report Date: 09/07/2022
Date Signed: 09/07/2022 02:55:09 PM

Document Has Been Signed on 09/07/2022 02:55 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:
(209) 330-7155
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 15CENSUS: 13DATE:
09/07/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Joseph NavarroTIME COMPLETED:
03:15 PM
NARRATIVE
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LPAs Albert Johnson and Kesha Lewis arrived to the facility unannounced to conduct a case management visit. LPAs met with Joseph Navarro.

LPA toured the facility with caregiver for a health and safety check. LPA inspected the interior and exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen.

LPAs confirmed that the department has not received requested quarterly financial records/documents. The facility will provide the department with the quarterly financial reports by close of business 9/12/2022.

Currently there are 13 residents in care for this visit.

Deficiencies were cited during this visit. Civil penalties assessed

Exit interview held, Appeal rights discussed, Copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
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 09/07/2022 02:55 PM - It Cannot Be Edited


Created By: Albert Johnson On 09/07/2022 at 02:13 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: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2022
Section Cited
CCR
80044(c)(1)

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(c) The licensing agency shall have the authority to inspect, audit, and copy client or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements specified in Sections 80066(c) and 80070(d). (1)The licensee shall ensure that provisions are made for the examination of all records relating to the operation of the facility.shall have the authority to inspect, audit, and copy client or facility records upon demand during normal business hours. Records may be removed if necessary, for copying. Removal of records shall be subject to the requirements specified in Sections 80066(c) and 80070(d).
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The Licensee will provide the department with the requested quarterly finiancal records by the close of business on 9/12/2022
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This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not provide financial statements and other requested financial documents requested by the Department’s auditor and did not have the documents readily available upon request from the Department. This posed a potential 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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022


LIC809 (FAS) - (06/04)
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