<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 01/20/2022
Date Signed: 01/20/2022 02:57:49 PM

Document Has Been Signed on 01/20/2022 02:57 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. 4FACILITY NUMBER:
392700627
ADMINISTRATOR:JESSICA OWENSFACILITY TYPE:
772
ADDRESS:8210 BRIGHT STREETTELEPHONE:
(209) 330-7155
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY: 15CENSUS: 15DATE:
01/20/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:Toni MarshallTIME COMPLETED:
01:47 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Johnson made an unannounced visit on this day for the purpose of conducting a Case Management, Health and Safety visit. LPA met with T. Marshall and explained the purpose of the visit.

Present at time of visit were 15 clients and 5 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 the client's bathrooms which measured 119 degrees F.

The facility was following the menu for today's lunch and dinner.

LPA inspected food supplies and observed two days worth of perishable and seven days worth of non-perishable foods.

LPA did not observe any signs of financial distress.

An exit interview was conducted with T. Marshall and a copy of this report provided.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1