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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700628
Report Date: 01/20/2022
Date Signed: 01/20/2022 01:06:42 PM

Document Has Been Signed on 01/20/2022 01:06 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: 13DATE:
01/20/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Fanesha Caldwell, Facility ManagerTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) T. White made an unannounced visit on this day for the purpose of conducting a Case Management, Health and Safety visit. LPA met with Fanesha Caldwell, Facility Manager and explained the purpose of the visit.

Present at time of visit were 13 clients and 3 staff. LPA inspected the interior and exterior of the facility. LPA verified that the facility had running water and electricity. LPA tested water temperature in the client shared bathrooms which measured 116.2 and 105.1 degrees F. LPA inspected food supplies and observed 7 days worth of perishable and 2 days worth of non-perishable foods.

LPA interviewed 3 staff and 5 clients regarding food supply and signs of financial distress. 2 of 3 staff interviewed did express concerns. 5 clients did not express concerns.

No deficiencies cited during inspection.

An exit interview was conducted with Facility Manager and a copy of this report given.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2022
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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