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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200678
Report Date: 01/24/2022
Date Signed: 01/24/2022 10:19:02 AM

Document Has Been Signed on 01/24/2022 10:19 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: 6DATE:
01/24/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Lisa Evans, AdministratorTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) G. Luk made an unannounced visit on this day for the purpose of conducting a Case Management, Health and Safety visit. LPA met with staff, Stacy Mitchell and explained the purpose of the visit. Administrator, Lisa Evans arrived 15 minutes later.

Present at time of visit were 6 clients and 2 staff. LPA inspected the interior and exterior of the facility. LPA verified that the facility had running water and electricity. LPA tested water temperature in client's bathroom which measured 120 degrees F. LPA inspected food supplies and observed 2 days worth of perishable and 7 days worth of non-perishable foods.

LPA interviewed 1 staff and 5 clients regarding food supply and signs of financial distress. Staff interviewed did not express concerns. 5 clients did not express concerns.

An exit interview was conducted with Lisa Evans. A copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2022
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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