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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 09/18/2024
Date Signed: 09/19/2024 10:51:07 AM

Document Has Been Signed on 09/19/2024 10:51 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/
DIRECTOR:		JESSICA OWENSFACILITY TYPE:
772
ADDRESS:8210 BRIGHT STREETTELEPHONE:
(209) 330-7155
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY: 15CENSUS: 14DATE:
09/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Administrator Jessica OwensTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived at this facility unannounced to conduct a case management visit. LPA Lund met with Administrator Jessica Owens and explained the purpose of the visit. Census: 14

The purpose of today's visit is to follow on Client (C1) moved to the facility on 9/16/2024. C1 came with all belongings and medications. LPA Lund followed up with C1 to see how the change of the facility is going with C1. Administrator Jessica Owens stated the C1 is transitioned well. C1 stated that C1 likes the facility.

No deficiencies were cited, per Title 22 Regulations. An exit interview was conducted, and a copy report left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2024
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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