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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 11/03/2023
Date Signed: 11/03/2023 02:05:15 PM

Document Has Been Signed on 11/03/2023 02:05 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
SACRAMENTO AC/SC, 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:
11/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Joseph Navarro TIME COMPLETED:
02:15 PM
NARRATIVE
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On November 03, 2023 At 9:00 AM, Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to deliver an Order of Exclusion for a staff member. LPA Lewis with Joseph Navarro and explained the purpose of today's visit.

LPA Lewis was informed by Joseph Navarro, the staff member named in the Order of Exclusion, Edmond, Rahas L., no longer works at the facility.

LPA Lewis provided Joseph Navarro with a copy of the Order and explained that Edmond, Rahas L. is not allowed in the facility effective immediately.

A tour of the kitchen area was conducted. A review of food supply was done to ensure a 2 day perishable and 7 day non-perishable food supply was available.

Exit interview was held, and a copy of this report and Immediate Exclusion letter were provided to the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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