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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 10/03/2023
Date Signed: 10/03/2023 01:00:34 PM

Document Has Been Signed on 10/03/2023 01:00 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:JESSICA OWENSFACILITY TYPE:
772
ADDRESS:8210 BRIGHT STREETTELEPHONE:
(209) 330-7155
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY: 15CENSUS: 15DATE:
10/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Alex ArchangelTIME COMPLETED:
01:15 PM
NARRATIVE
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On 10/3/23 at approximately 12:15pm Licensing Program Analyst (LPA) Jennifer Fain arrived at this facility unannounced to conduct a case management visit. LPA met with Alex Archangel, Regional Program Manager (RPM), and explained the purpose of the visit.

A review of LIS facility file shows that this facility is out of compliance regarding its licensing fees. The facility was billed 6/1/23. Community Care Licensing (CCL) has not received payment as of 10/2/23.

The facility is not in compliance with the Health and Safety Code, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Alex Archangel and a copy of the LIC 809 reports, LIC 809-D pages, and Appeals rights were provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Jennifer Fain
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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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Document Has Been Signed on 10/03/2023 01:00 PM - It Cannot Be Edited


Created By: Jennifer Fain On 10/03/2023 at 12:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: G.L.O.M. A.R.F. 4
FACILITY NUMBER: 392700627

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2023
Section Cited
HSC
1523.1

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Fees or taxes on license (a)(1) An application fee ... shall be charged by the department for ... a license...., a fee shall be charged by the department annually on each anniversary of the effective date of the license.This requirement is not met as evidenced by:
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Regional Program Manager will send plan of correction by end of business on 10/6/23 to jennifer.fain@dss.ca.gov.
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Based on record review, the licensee did not submit payment by the required due date which poses a potential Health, Safety or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Jennifer Fain
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2023


LIC809 (FAS) - (06/04)
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