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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700752
Report Date: 01/10/2023
Date Signed: 01/10/2023 01:24:07 PM

Document Has Been Signed on 01/10/2023 01:24 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: 44DATE:
01/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Anthony Isbell - AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met with administrator and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 46 ambulatory clients.

LPA and administrator toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and side yard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 72.6 degrees Fahrenheit. Hot water measured at 110.4 degree Fahrenheit in resident's shared bathroom which is within the required regulation of 105 to 120 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7 day non-perishable and 2 day perishables foods. LPA observed smoke detectors are interconnected with the fire department. LPA observed carbon monoxide in operating condition during inspection. Fire extinguishers were last serviced on 1/10/2022. LPA observed completed mitigation plan. LPA reviewed six (6) resident and four (4) staff files, including criminal record clearances. Three staff were missing current first aid certificates. Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.

LPA requested the following forms to be submitted via email by February 6, 2023:
LIC 308, LIC 610-D, Surety Bond, and Administrator Certificate.

See deficiency cited from the California Code of Regulations, Title 22, and California Health and Safety Code.

Exit interview held with Administrator and a copy of report given at the conclusion of the visit.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2023
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 01/10/2023 01:24 PM - It Cannot Be Edited


Created By: Ruth Wallace On 01/10/2023 at 01:07 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: 01/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in three of the staff did not have current first aid certificates in personnel files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2023
Plan of Correction
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 Licensee agrees to submit via email to LPA three staff current first aid certificates by Plan of Correction Date 1/17/2023.
ruth.wallace@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Ruth Wallace
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023


LIC809 (FAS) - (06/04)
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