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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 09/16/2022
Date Signed: 09/16/2022 05:14:37 PM

Document Has Been Signed on 09/16/2022 05:14 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:
09/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Alex ArchangelTIME COMPLETED:
05:00 PM
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On 9/16/22 Licensing Program Analyst (Maja Jensen) arrived unannounced to conduct a case management visit related to food service. LPA Jensen met with Alex Archangel and explained the purpose of todays visit.

LPA Jensen toured the pantry and the kitchen. The facility was observed to have an emergency food supply, 2 days of perishable food and 7 days of non-perishable food. There was 11-4lb packages of chicken, 60 hamburger patties and 9 lbs of hot dogs observed in the freezer. The pantry contained various cereals, panckaes, canned beans and vegetables. There were also snacks observed on hand for the residents including fruit snacks, popcorn and chips. In addition the facility was observed to be maintaining an emergency water.

No deficiencies are being cited as a result of this case management.

An exit interview was conducted and a copy this report was given Alex Archangel.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
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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