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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700628
Report Date: 04/25/2024
Date Signed: 04/25/2024 02:05:57 PM

Document Has Been Signed on 04/25/2024 02:05 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:G.L.O.M. A.R.F. 5FACILITY NUMBER:
392700628
ADMINISTRATOR/
DIRECTOR:		JESSICA OWENSFACILITY TYPE:
772
ADDRESS:458 ALMOND DRIVETELEPHONE:
(209) 330-7155
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 16CENSUS: 15DATE:
04/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:46 AM
MET WITH:Jessica Owens and Alex ArchangelTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 04/25/2024 at 8:46 AM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Jessica Owens and Alex Archangel and explained the purpose of the visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator's certificate expired in January of 2024, and renewal application was submitted to the Department. The renewal application is pending. The facility is licensed for sixteen ambulatory clients only. There are currently fourteen clients who reside at this facility.

The LPA Martinez toured the facility with Jessica Owens on 04/25/2024 at 1:00 PM.

During today's annual inspection ten client files and ten staff files were reviewed. Staff files were complete. Client' 1 Physician report was complete; however, client's 1 tuberculosis chest results were not available at time of visit. LPA Martinez requested a copy of client's 1 chest exam and a copy of the current fire inspection report. Documents will be emailed to LPA Martinez by 5:00 PM on April 25, 2024. A technical violation was given due to not having client 1's chest exam available at time of visit. LPA Martinez reviewed 5 Medication Administration Records (MAR), and MARs were completed and maintained. Facility has a emergency disaster plan and infection control plan. The facility's last fire drill was on April 15, 2024. LPA Martinez reviewed two PNI documents, and the documents were complete and maintained. The facility has liability insurance and surety bond.

Continued...

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: G.L.O.M. A.R.F. 5
FACILITY NUMBER: 392700628
VISIT DATE: 04/25/2024
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The facility has an adequate food supply, and the kitchen area was sanitary. The facility water temperature measured at 110 degrees, and the facility temperature measured at 72 degrees. The facility bedrooms were furnished and sanitary. The laundry room, bathrooms, and common areas were sanitary and furnished. The facility also has a public telephone for client use. The facility fire extinguishers are in good repair, and the emergency exit gate is in good repair.

As a result, of this annual inspection, a technical violation was given to the facility, and there were no deficiencies cited. An exit interview was conducted, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC809 (FAS) - (06/04)
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