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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 247209076
Report Date: 12/09/2021
Date Signed: 12/09/2021 12:39:21 PM

Document Has Been Signed on 12/09/2021 12:39 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:G.L.O.M.A.R.F. 10FACILITY NUMBER:
247209076
ADMINISTRATOR:EVANS, LISAFACILITY TYPE:
735
ADDRESS:1259 LURS CTTELEPHONE:
(925) 570-3282
CITY:MERCEDSTATE: CAZIP CODE:
95348
CAPACITY: 6CENSUS: 5DATE:
12/09/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Emily Beckwith, Program DirectorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Lady Cabrera arrived unannounced to conduct a Health and Safety Inspection. Acting Administrator Lisa Evans was unavailable and Designated Representative Emily Beckwith, Program Director to meet with LPA. LPA explained the purpose of the visit. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Bedrooms were checked. LPA checked residents’ medications. Food supply was checked and there appeared to be an adequate supply. The exterior tour was conducted.

No deficiencies cited during today's inspection. Exit interview was conducted. LPA provided a copy of this report to Designated Representative.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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