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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700752
Report Date: 04/01/2026
Date Signed: 04/01/2026 03:25:01 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2026 and conducted by Evaluator Noel Wolf Petersen
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20260122085942
FACILITY NAME:G.L.O.M. A.R.F. 6FACILITY NUMBER:
392700752
ADMINISTRATOR:ALEXANDRIA ARCHANGELFACILITY TYPE:
735
ADDRESS:404-408 E. PINE STTELEPHONE:
(209) 330-7155
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:46CENSUS: 46DATE:
04/01/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Angie ChavezTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not providing nutritious meals.
Staff are not providing adequate meal service to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA, Noel Wolf Petersen arrivied unannounced to the facility to deliver findings related to a complaint with the above allegations. LPA met with the Facility Manager Angie Chavez to explain the purpose of the visit.

Regarding the allegation of staff not providing nutritious meals, In interview with 4 kitchen staff made concensus statement that perscribed diets and allegies of the clients are rarely made known to them. The facility did provide a list of diabetic clients to the kitchen staff, with no representation for the hypertensive, calorie restriction or other perscribed diet order. In at least one instance in the recent past, kitchen staff recalled a client, R4 with a perscribed diet order that was not accomodated by the kitchen. Through record review of the clients 602's it was learned that R4 did have a perscribed diet for hypertensive and calorie restiction type diet order. The facility provided the statement that there is now a process for relaying all perscribed diets and allergy information to the kitchen staff.

Continued on C Page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
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 3
Control Number 27-AS-20260122085942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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. 6
FACILITY NUMBER: 392700752
VISIT DATE: 04/01/2026
NARRATIVE
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Regarding the allegation that staff are not providing adequate meal services, In Kitchen staff interview it was learned that there was no designated staff for leading the design the menu at the start of the complaint, and now a designated staff has been promoted to a lead position. Facility staff originally provided that at the time of the complaint, no single person was given the responsibility as lead. 1 kitchen staff supported the statement that the lead has since been able to shop for ingredients in a timely fashion, and has since been able to switch items to accommodate alternative diets without a loss of nutrition.

Secondary to not having a person in charge of the kitchen, were many adjacent issues. In interview, it was learned in staff interviews that R1 was not allowed to eat a fruit by a staff during a meal service, another R2 that was not permitted by a staff to get a snack from their personal property locker to supplement a meal service, and a third R3 was eating the alternative meal(peanut butter and jelly sandwitch) for weeks at a time. On the 2 meal services the LPA witnessed, clients were allowed to partake of the availible fruits if they wanted with no limitation to kind or quantity, there was no client desiring supplemental food from their personal storage, and the client making excessive use of the alternate meal plan was fully participating with the regular menu. In 1 of 3 clients interviews it was corroborated that the client involved was not allowed to eat a fruit, the client stated she was told "This is for everybody", from the staff when denied the fruit. Two staff corroborated the incident where a client was not allowed to supplement a meal with a personal snack.

On the Visits, LPA observed food serving temperature being moderated with serving pans over the stove during the second meal observation visit(first visit was a sandwitch and chips), to be served to the clients. Some food reserved from previous meals to be served had not been labeled with dates on the first inspection(tacos and rice salad), all foods were labeled on the second kitchen inspection. During the second visit, 1 Kitchen staff report a lessening of the cockroaches due to a spray of pesticide since the the first visit.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. Citations on a following D Page.

LPA left a copy of the report with the Facility Manager Angie Chaves electronicly, and provided a copy of the appeal rights. the report was read and an exit interview was conducted.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20260122085942
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
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. 6
FACILITY NUMBER: 392700752
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2026
Section Cited
CCR
85065(e)(2)(a)
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85065 Personnel Requirements (e) The licensee shall ensure that the following personnel requirements are met in the provision of food service: (2)In facilities with a licensed capacity of 16 or more clients an employee shall be designated to have primary responsibility for food planning, preparation and service. (A) The designated employee shall receive on-the-job training or shall have related experience as evidenced by safe and effective job performance.
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No immediate POC, there is a dedicated person who has taken on increased responsibilities as to menu planning, food preperation, and service.
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This requirement was not met as evidenced by: interview with kitchen staff where no single person amongst them was identified as having primary responsibilities as above, interview with staff and clients where 2 client's were having food items restricted and another client was not meeting the nutritional servings for long periods of time(weeks),
Not following this requirement posed a risk to the health saftey and personal rights to clients in care.
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Type B
04/29/2026
Section Cited
CCR
80076(a)(6)(A)
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80076(a)(6)(A) Food Services: (a) In facilities providing meals to clients, the following shall apply:( 6) Modified diets prescribed by a client's physician as a medical necessity shall be provided. (A) The licensee shall obtain and follow instructions from the physician or dietitian on the preparation of the modified diet.
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Audit the 602 client files for perscribed diets, reorganize the menu items offered as neccessary to make alternative meal choices reflect the ability of perscribed diet users to follow thier diet. LPA gave guidance it would be a good idea to do the same for allergies.
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This requirement was not met as evidenced by: interview with kitchen staff where all recall at least one a client that was not recieving a perscribed diet order. Record revew indicated the client had a perscribed diet order. Not following this requiremt posed a risk to the health and saftey and personal rights 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: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3