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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700629
Report Date: 05/16/2024
Date Signed: 05/16/2024 10:33:14 AM

Document Has Been Signed on 05/16/2024 10:33 AM - 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. 3FACILITY NUMBER:
392700629
ADMINISTRATOR/
DIRECTOR:		ALEXANDRA ARCHANGELFACILITY TYPE:
772
ADDRESS:1117 SOUTH GRANT STREETTELEPHONE:
(209) 330-7155
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 15CENSUS: 15DATE:
05/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Karen Edmond and Alex ArchangelTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced on 05/16/2024 at 8:45 AM to conduct a case management visit. LPA Martinez met with Karen Edmond and Alex Archangel and explained the purpose of the visit.

The purpose of today's visit is to follow up on learned deficiencies during a complaint investigation 27-AS-20240508105753, and to ensure the facility is in compliance with applicable statutes and regulations.

During complaint 27-AS-20240508105753 investigation, it was learned clients were receiving care and supervision and other community services at an unlicensed care facility. As a result, the facility is not following the approved plan of operation that was submitted to the Community Care Licensing Department (CCLD). Any significant changes in the plan of operation which would affect the services to clients shall be submitted to the licensing agency for approval. Therefore, the facility Licensee will need to submit an updated plan of operation to CCLD if clients will return to any G.L.O.M community center. Please submit updated plan of operation to CCLD by June 03, 2024 if any changes are made that will affect client services. CCLD will review the plan of operation for approval once received. As a result, deficiencies have been cited for not following plan of operation. In addition to, administrator qualification due to not conforming to the applicable laws, rules and regulations.

Moreover, during today's visit, LPA Martinez conducted interviews and requested documents. The requested documents are the following: Facility LIC 500 Personnel Report and staff schedules, which were provided during today's visit. Facility staff will email LPA Martinez March, April, and May 2024 payroll/time cards by May 24, 2024 by 5:00 PM. Also, during today's inspection, LPA Martinez observed fair labor law postings in the facility. As a result of this visit, the following deficiencies were cited, per Title 22 Regulations. Deficiencies can be found on the 809-D page. An exit interview was conducted, and a copy of this report, 809D page, and appeals rights were provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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 05/16/2024 10:33 AM - It Cannot Be Edited


Created By: Avelina Martinez On 05/16/2024 at 09:45 AM
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: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
06/03/2024
Section Cited
CCR
87208(a)

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87208(a) Plan of Operation: Each facility shall have and maintain a current, written definitive plan of operation... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval...This requirement was not met as evidence by:
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Facility staff agreed to provide a plan for an updated plan of operation by POC date 06/03/2024 by 5:00 PM.
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Based on visit inspections, file review, and interviews, the Licensee did not ensure that the CCLD approved plan of operation was being followed, and/or did not submit an updated plan of op to CCLD for significant changes that affected the services to clients. This posed a potential health and safety risk to clients.
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Deficiency Dismissed
Type B
06/03/2024
Section Cited
CCR87405(d)(2)

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87405(d)(2) Administrator Qualifications & Duties: The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidence by:
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Facility staff agreed to agreed to review Title 22 Regulations...87405 and 87208 by POC date 06/03/2024. Confirmation of review email shall be emailed to LPA Martinez by POC date 06/03/2024 5:00 PM.
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based on file reviews and interviews. The Administrator did not ensure to conform to Title 22 Regulations and did not implement plan of operation Title 22 regulations. This posed a potential health and safety risk 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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Avelina Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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