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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 06/09/2023
Date Signed: 06/09/2023 12:51:26 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/09/2023 12:51 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:
06/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Karen EdmondTIME COMPLETED:
01:00 PM
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On 6/9/23 at approximately 11:15am Licensing Program Analysts Maja Jensen and Jennifer Fain arrived at facility unannounced to continue an annual inspection which was commenced on 5/26/23. LPA's Jensen and Fain and met with facility Manager Karen Edmond and explained the purpose of today's visit.

LPA Jensen toured the facility grounds and physical plant. The grounds were maintained and clear of debris. There are no bodies of water on the property. LPA Jensen observed outdoor furniture and shaded areas available for the clients to enjoy outdoor activities. There are raised planter boxes available for any clients interested in gardening.

LPA Jensen toured the physical plant and observed it to be sanitary and free of order. There is adequate lighting and furniture throughout. The facility maintains a variety of activities for client engagement and a calendar of events/outings.

LPA Jensen toured the kitchen and observed in excess of a two day supply of perishable food and a 7 day supply of non-perishable food. The knives and other sharp objects are stored in a separate room and locked. Medications and toxins are also kept locked and inaccessible to residents in care. The facility maintains a first aid kit complete with scissors, tweezers, thermometer, manual and various wound dressings. There is an emergency supply of food, water and lighting available. The fire extinguisher was last serviced in January 2023 and is in compliance. The smoke detectors and carbon monoxide detector were determined to be in good working order. The facility has posted signs for infection mitigation, resident rights and abuse/compliant reporting. All staff were verified as being associated and having the appropriate background clearance.

LPA Jensen checked client P&I funds for client 1 (C1) and determined the accounting to be accurate. LPA Jensen reviewed 2 staff files and determined them to be complete. LPA's Jensen and Fain reviewed 5 resident files and determined them to be complete. Continued on LIC 809C...
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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. 4
FACILITY NUMBER: 392700627
VISIT DATE: 06/09/2023
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LPA Jensen requested and received a copy of the Surety Bond and LIC 500. The facility has a current Surety Bond for $7500.

The facility will email the Liability Bond to LPA Jensen by 6/16/2023.

The facility was determined to be in substantial compliance and no deficiencies were cited as a result of this visit.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
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