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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 05/12/2022
Date Signed: 06/06/2022 03:32:03 PM

Document Has Been Signed on 06/06/2022 03:32 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jessica Owens, AdministratorTIME COMPLETED:
01:00 PM
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On 05/12/2022 at 9:15am, Licensing Program Analysts (LPAs) T. White and R. Campbell arrived unannounced to conduct a required 1-year Annual inspection. LPAs met with Facility Manager, Sylvester Finley, regarding facility risk assessment questions. LPAs later met with Administrator, Jessica Owens and explained the purpose of today's inspection. LPAs were allowed entry into the facility that is licensed to serve a total capacity of 15 ambulatory clients.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. Hot water temperature in the shared clients’ bathroom was measured at 122 degrees Fahrenheit. LPAs observed hot water temperature signs throughout the facility. LPAs observed lighting in all rooms is adequate for the comfort and safety of the clients. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day non-perishable and 2-day perishables foods.

LPAs observed smoke detectors are interconnected with the fire department and carbon monoxide alarm in operating condition. Fire extinguisher was last serviced on January 16, 2022. LPAs observed mitigation plan completed. First aid kit observed to be complete. Fire drill was last conducted on 5/10/2022.

Based on today’s inspection, Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed or cited today.

An exit interview was conducted with Administrator and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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