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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 12/12/2023
Date Signed: 12/12/2023 10:07:44 AM

Document Has Been Signed on 12/12/2023 10:07 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
12/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Alex Archangel TIME COMPLETED:
10:15 AM
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An unannounced case management visit was conducted by the Licensing Program Analyst (LPA) Avelina Martinez on 12/12/2023 at 9:15 AM. LPA Martinez met with Alex Archangel and explain the purpose of the visit.

The purpose of the visit is to follow up on an incident report received at Community Care Licensing Department (CCLD). The report stated on 11/17/2023 at 4:00 PM, R1 walked out of the facility while in crisis. Facility staff followed R1 outside, and staff were able to keep line of sight. Facility staff called law enforcement, and R1 was able to be redirected. R1 was transferred to a crisis center. At this time, R1 has not returned to G.L.O.M 4.

There were no deficiencies cited at this visit. An exit interview was conducted, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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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