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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700628
Report Date: 05/19/2023
Date Signed: 05/19/2023 02:47:56 PM

Document Has Been Signed on 05/19/2023 02:47 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 AC/SC, 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:
(209) 330-7155
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 16CENSUS: 15DATE:
05/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jessica Owens, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year Required visit on this date. LPA met and toured with Administrator, Jessica Owens. The administrator currently holds a certificate (#6055006735) that expires on 01/07/2024. The facility’s fire extinguishers were last inspected on 01/20/24.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. The hot water temperature is maintained at 109 degrees Fahrenheit. All outdoor and indoor passageways were kept free from obstruction. Rooms were furnished appropriately. There was an adequate supply of toiletries, hygiene supplies, and extra linens. LPA observed clients’ linens were in good repair. There is a minimum of 7-day nonperishables and 2-day perishables foods.

LPA Campbell reviewed 3 of 15 resident files and 3 of 12 staff files. LPA compared resident medication and medication dispensing logs. Smoke detectors and carbon monoxide were connected to the fire department.. LPA reviewed staff record files and the facility has sufficient staffing to provide the services needed to meet the clients’ needs. All staff have criminal record clearance and are associated to the facility. LPA reviewed clients’ files No deficiencies issued during the visit.

Exit interview conducted with Administrator and a copy of this report was provided

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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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