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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700628
Report Date: 01/06/2022
Date Signed: 01/06/2022 02:22:05 PM

Document Has Been Signed on 01/06/2022 02:22 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. 5FACILITY NUMBER:
392700628
ADMINISTRATOR:JESSICA OWENSFACILITY TYPE:
772
ADDRESS:458 ALMOND DRIVETELEPHONE:
(925) 570-3282
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 16CENSUS: 15DATE:
01/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Jessica Owens, AdministratorTIME COMPLETED:
12:40 PM
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On 01/06/2022, Licensing Program Analyst (LPA),T. White, conducted an unannounced case management visit to follow up on an AWOL incident, which occurred on 12/28/2021. LPA met with Administrator, Jessica Owens and explained the purpose of the visit.

LPA White reviewed the incident report submitted to CCLD on 12/28/2021. Based on incident report, Client #1 (C1) was transported to Crisis for a re-evaluation per county clinician, C1 refused to go into the Behavioral Center and took off running. Staff searched surrounding areas and made contact with C1. C1 refused to enter the van. Based on C1's Physician report, C1 is able to leave unassisted.

Based on interview with Staff #1 (S1), S1 filed a police report and informed C1's mother.S1 confirmed C1 moved back with his mother. S1 informed C1's mother to take C1 back to the crisis center for further evaluation, if needed. LPA reviewed how the facility is working with clients to prevent further AWOLs.

No deficiencies were cited today.

Exit interview was conducted with Administrator and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2022
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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