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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 01:25:42 PM

Document Has Been Signed on 05/10/2024 01:25 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:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Alex Archangel and Joseph Navarro and AJ LandTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On May 10, 2024 at 1:00 PM, Licensing Program Analyst (LPA) Avelina Martinez arrived to the facility unannounced to conduct a case management inspection. LPA Martinez met with Alex Archangel and Joseph Navarro and AJ Land and explained the purpose of today's visit.

The purpose of the visit today is to ensure the facility is in compliance with applicable statutes and regulations.

During today's visit, LPA Martinez conducted interviews and requested documents. The requested documents are the following: Facility LIC 500 Personnel Report and staff schedules. Facility staff will email LPA Martinez March, April, and May 2024 ayroll/time cards by May 17, 2024 by 5:00 PM. Moreover, during today's inspection, LPA Martinez observed fair labor law postings in the facility.

There were no deficiency cited during today's inspection. 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: 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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