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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700752
Report Date: 03/24/2021
Date Signed: 03/24/2021 11:22:01 AM

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. 6FACILITY NUMBER:
392700752
ADMINISTRATOR:ANTHONY ISBELLFACILITY TYPE:
735
ADDRESS:404-408 E. PINE STTELEPHONE:
(209) 330-7155
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:46CENSUS: 45DATE:
03/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Anthony IsbellTIME COMPLETED:
11:30 AM
NARRATIVE
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On 3/24/2021 at 11am Licensing Program Analyst (LPA) Ashley Boothe contacted Administrator Anthony Isbell and stated the purpose of the visit. A physical visit was not conducted in that the Department is not conducting visits due to COVID-19. Current Census 45.

LPA reviewed records and interviewed staff for an incident of Resident one (R1's) missed medications. On 10/10/2020 R1 visited primary care physician and prescribed medication one (M1) once daily to better control R1's medical conditions. Centrally Stored Medications Log document M1 filled on 10/12/2020 by BJRX pharmacy and not started until 10/19/2020. Medication Administration Records (MAR) document first administration to R1 on 10/20/2020. Staff interviewed were unsure why the medication was not started once received before 10/19/2020 and not administered to R1 until 10/20/2020. ADM stated facility's process for medications delivered from BJRX pharmacy to the facility are the same day or the next day after a prescription is sent from a physician. Prescriptions sent to a different local pharmacy, the Facility Manager would be notified by med-tech go pick it up that day.

Deficiencies were cited per Title 22 Regulations. Exit interview was conducted with Anthony. Copy of the report was sent to via e-mail with a "read receipt" to verify the LIC 809, LIC809D, and Appeal Rights were received. Anthony is to print out the report and fax signed copies to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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. 6
FACILITY NUMBER: 392700752
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2021
Section Cited

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (5)The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidence by:
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Based on records reviewed and interviews the licensee did not assist in administering R1's medication one (M1) from when M1 was ordered by physican on 10/10/2020, filled on 10/12/2020 and not started until 10/20/2020 as documented R1's MAR which poses 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.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2021
LIC809 (FAS) - (06/04)
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