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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700752
Report Date: 10/07/2021
Date Signed: 10/07/2021 03:48:30 PM

Document Has Been Signed on 10/07/2021 03:48 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. 6FACILITY NUMBER:
392700752
ADMINISTRATOR:ANTHONY ISBELLFACILITY TYPE:
735
ADDRESS:404-408 E. PINE STTELEPHONE:
(209) 330-7155
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 46CENSUS: 46DATE:
10/07/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Peggy Phelps, DirectorTIME COMPLETED:
04:00 PM
NARRATIVE
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On 10/07/2021, Licensing Program Analyst (LPA) arrived unannounced to conduct a health and safety check. LPA met with Peggy Phelps, Director and Anthony Isbell, Administrator. LPA explained the purpose of the visit.

LPA spoke with Vice President (VP) via telephone regarding clients moving out due to the County finding placement. VP stated there is currently 46 clients who reside in the home and will be moving out by October 23, 2021. VP stated the facility has a plan to move additional 46 clients from other counties back into the facility after October 23, 2021. LPA toured the facility and observed 18 clients and 6 staff members. LPA observed clients belongings have not been moved out of the facility. Director stated 46 clients will be moving out of facility by October 23, 2021.

- During facility tour, LPA observed insufficient supply of food.

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 and Administrator. A copy of report and Appeal rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/07/2021 03:48 PM - It Cannot Be Edited


Created By: Treana White On 10/07/2021 at 03:36 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. 6
FACILITY NUMBER: 392700752

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2021
Section Cited
CCR
85076(d)(1)

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85076(d)(1): Food Service: The licensee shall meet the following food supply and storage requirements:(1)Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
This requirement was not met as evidence by:
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Director and Administrator agreed to complete grocery shopping. Director will submit photos and receipt by POC date.
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Based on LPA observation, Facility did not comply with the section cited above in 85076(d)(1). LPA observed insufficient supply of food which poses as an immediate 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:Treana White
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2021


LIC809 (FAS) - (06/04)
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