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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700752
Report Date: 01/18/2022
Date Signed: 01/18/2022 03:40:01 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2022 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220110113925
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: 30DATE:
01/18/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Alexandria Archangel, Program DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility is not sanitizing dishes and utensils by an alternative comparable method
INVESTIGATION FINDINGS:
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On 01/18/2022 at 12:00pm, Licensing Program Analyst (LPA) T. White arrived unannounced to open and investigate the complaint allegation noted above. LPA met with Program Director, Alexandria Archangel and explained the purpose of the visit.

During course of investigation, LPA toured the kitchen and food storage area. LPA interviewed 4 staff members. Based on inspection, LPA observed no sanitizer solution for dishes/utensils available during inspection. LPA observed no commercial dishwasher present at the facility. LPA observed hot water temperature in the kitchen measured at 103.5 degrees F.

Based on 4 staff interviews, 4 of 4 staff stated there is only Dawn dish soap available at this time. 4 of 4 staff stated there is no sanitizer solution for dishes available at this time. LPA observed, Staff #1 (S1) washing pots and pans with water and Dawn dish soap. Based on observation, facility is not sanitizing dishes and utensils by an alternative comparable method.
Report continues on 9099C.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2022 and conducted by Evaluator Treana White
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220110113925

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: 30DATE:
01/18/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Alexandria Archangel, Program DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility kitchen is dirty
INVESTIGATION FINDINGS:
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On 01/18/2022 at 12:00pm, Licensing Program Analyst (LPA) T. White arrived unannounced to open and investigate the complaint allegation noted above. LPA met with Program Director, Alexandria Archangel and explained the purpose of the visit.

During course of investigation, LPA toured the kitchen and food storage areas. LPA interviewed 4 staff members. Based on observation, facility kitchen and food storage areas was clean. Based on interviews, 4 of 4 staff stated the kitchen staff cleans the kitchen throughout the day. LPA was unable to interview clients based on staff interviews. 4 of 4 staff stated clients are not allowed in the kitchen or food storage areas. However, LPA is unable to prove or dissprove if facility kitchen was dirty.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Program Director and a copy of report given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20220110113925
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2022
Section Cited
CCR
80076(a)(20)(B)
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80076(a)(20)(B): Food Services: (20) All dishes and utensils used for eating and drinking and in the preparation of food and drink, shall be cleaned and sanitized after each usage.(B) Facilities not using dishwashing machines shall clean and sanitize dishes and utensils by...
This requirement was not met as evidence by:
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Director agreed to purchase sanitizing solution for dishes and utensils. Director agreed to adjust hot water temperature. Director will submit proof to CCLD by POC date.
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Based on observation and interviews, facility did not comply with the section cited above in 80076(a)(20(B). Based on observation, facility did not have sanitizing solution during inspection which poses as an immediate health and safety risks 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220110113925
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 01/18/2022
NARRATIVE
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Based on LPA's observation and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview with Program Director. A copy of report and Appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4