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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200678
Report Date: 12/10/2021
Date Signed: 12/10/2021 10:05:51 AM

Document Has Been Signed on 12/10/2021 10:05 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:G.L.O.M. ARFFACILITY NUMBER:
019200678
ADMINISTRATOR:TURNER, ALLEN DRFACILITY TYPE:
735
ADDRESS:2066 WALNUT STREETTELEPHONE:
(925) 583-5775
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 6CENSUS: 5DATE:
12/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Jessica Turner, Program DirectorTIME COMPLETED:
10:20 AM
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On 12/10/2021 at 8:18AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Nadine Lukong and explained the purpose of the visit. Program Director, Jessica Turner arrived 20 minutes later.

Upon entry, LPA's temperature was checked, and LPA observed hand sanitizer and hand washing sign at screening station. LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, kitchen, storage shed, and outdoor area. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations.


During record review, LPA observed visitors log and temperature log for staff & clients. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food, and paper supplies are sufficient.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2021
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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