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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700752
Report Date: 07/27/2022
Date Signed: 07/27/2022 10:47:15 AM

Document Has Been Signed on 07/27/2022 10:47 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
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: 39DATE:
07/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Adriana Palacios, Case Management SupervisorTIME COMPLETED:
11:00 AM
NARRATIVE
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On 07/27/2022, Licensing Program Analyst (LPA) T. White conducted an unannounced case management visit to follow up on an AWOL incident resulting in client death, which occurred on 07/24/2022. LPA met with Adriana Palacios, Case Management Supervisor and Janine Herera, Clinical Supervisor. LPA explained the purpose of the visit.

Based on incident report on 07/24/2022, at 6:30 PM Client #1 (C1) left the facility unauthorized. Staff followed and encouraged C1 to return to the facility. C1 returned to the facility with staff at approximately 6:49 PM. Upon return, C1 immediately fled the facility again. Staff immediately followed loosing sight of C1 a block away from the facility. Staff conducted a search surrounding area. Staff immediately followed C1 who began sprinting and could not locate a short while after sprinting. During search, staff were alerted to several officers in a nearby alley surrounding a home. Staff were told by police to stand down. During police and client interaction, staff were notified by police that C1 had passed away. Based on staff interviews, staff are unsure how C1 passed away. Facility will request police report regarding incident.

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 was conducted with Case Management Supervisor and . A copy of report given and Appeal Rights given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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 07/27/2022 10:47 AM - It Cannot Be Edited


Created By: Treana White On 07/27/2022 at 10:23 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
, 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: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2022
Section Cited
HSC
1569.312(d)

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Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services:...(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community.

This requirement is not met as evidence by:
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The facility agreed to conduct an in-service training with staff to go over what and how staff shall ensure that client do not AWOL. Administrator will submit proof to CCLD by POC date.
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Based on incident report, the facility failed to comply with section cited above in 1569.312(d). Based on incident report, C1 AWOL'D from facility that resulted in C1's death which poses 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: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
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