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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 01/26/2024
Date Signed: 01/26/2024 09:27:08 AM

Document Has Been Signed on 01/26/2024 09:27 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:
01/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joseph Navarro TIME COMPLETED:
09:45 AM
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On January 26, 2023, Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA met with Joseph Navarro and explained the purpose of the visit.

The purpose of the visit today, is in response to follow up on water supply clearance- complaint 27-AS-20230926165820. LPA Martinez conducted an inspection of the water supply unit with Joseph Navarro on 01/26/2024. Facility staff reported dual osmosis unit that filters the all of the well water that is supplied to the facility. LPA Martinez requested a copy of the water supply plan and maintenance plan of the dual osmosis unit, and how the facility is ensuring water is safe for consumption by residents in care. Please email plans by 1/31/2024 by 5:00 PM.

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: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2024
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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