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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 05:18:03 PM

Document Has Been Signed on 09/16/2022 05:18 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:POCUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Alex ArchangelTIME COMPLETED:
05:30 PM
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On 9/16/22 at approximately 4:30pm, Licensing Program Analyst (LPA) Maja Jensen arrived at facility to conduct a case management related to the licensing agency's request for financial documents. LPA Jensen met with Alex Archangel and explained the purpose of today's visit.

During the course of the visit LPA Jensen also spoke to the Director of Accounting and Finance as well as the Board Secretary by phone. An account summary was reviewed through which LPA Jensen was able to clear the plan of correction

No further deficiencies were cited as a result of this visit.

An exit interview was conducted and a copy of this report was handed to 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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