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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700627
Report Date: 03/09/2023
Date Signed: 03/09/2023 11:47:27 AM

Document Has Been Signed on 03/09/2023 11:47 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
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: 14DATE:
03/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lisa Evans and Karen EdmondTIME COMPLETED:
12:00 PM
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On 3/9/23 at approximately 10am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to conduct a case management related to an incident report received for an occurrence on 12/9/22. LPA Jensen was joined by Lincoln Ellis, Sharmaine Roberts and Cynthia Poulos from the San Joaquin County Behavioral Health Department.

LPA Jensen interviewed Licensee Lisa Evans and site manager Karen Edmond regarding an incident that occurred on 12/9/22. On that date at approximately 8:45pm, resident 1 (R1) became agitated and aggressive with staff 1 (S1) over not getting a cigarette, knocked S1 down and caused injuries that required medical attention. 911 was called and S1 was taken to the hospital. R1 was taken in to custody and is still in custody to the best of facility staff's knowledge.

LPA Jensen reviewed R1's pre-placement appraisal, functional capabilities assessment, Crisis Response Team (CRT) flowchart and charting notes for the date in question. No deficiencies are being cited during the course of this visit. ]

An exit interview was conducted and a copy of this report and confidential names list was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Maja Jensen
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
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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