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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 05/10/2024
Date Signed: 05/10/2024 01:26:22 PM

Document Has Been Signed on 05/10/2024 01:26 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:G.L.O.M. A.R.F. 4FACILITY NUMBER:
392700627
ADMINISTRATOR/
DIRECTOR:
JESSICA OWENSFACILITY TYPE:
772
ADDRESS:8210 BRIGHT STREETTELEPHONE:
(209) 330-7155
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY: 15CENSUS: 15DATE:
05/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:49 AM
MET WITH:Alex Archangel and Joseph Navarro and AJ LandTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 05/10/2024 at 9:49 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Alex Archangel, Joseph Navarro, and AJ Land and explained the purpose of the visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate, The facility is licensed for 15 ambulatory clients. There are currently 15 clients who reside at this facility.

The LPA Martinez toured the facility with AJ Land on 05/10/2024 at 12:10 PM.

LPA Martinez reviewed eight client files and eight staff files, and the files were maintained. The Last fire drill was on May 01, 2024 and emergency disaster drill was conducted on May 02, 2024. The facility has a natural disaster plan, an emergency preparedness plan, and an infection control plan. LPA Martinez reviewed two PNI ledgers, and the documents were maintained. LPA Martinez reviewed two medication administration records, and both were maintained. Requested documents received during today's visit were the following: liability insurance and surety bond. The bacteriological analysis annual inspection is due in October of 2024.

The facility has an adequate food supply, and the dinning area and kitchen were sanitary. The facility laundry room was sanitary, and toxins are stored in a locked room. Moreover, common areas, bedrooms, and bathrooms were furnished and sanitary. The fire extinguishers are in good repair.

As a result of this annual inspection visit, there were no deficiencies cited. An exit interview was conducted, and a copy of this 809 report was provided to the facility at the end of the visit.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2024
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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