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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700628
Report Date: 11/02/2023
Date Signed: 11/02/2023 10:08:42 AM

Document Has Been Signed on 11/02/2023 10:08 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 13DATE:
11/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Alexandria ArchangelTIME COMPLETED:
10:15 AM
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On November 02, 2023 At 10:00 AM, Licensing Program Analyst (LPA) Avelina Martinez  arrived unannounced to deliver an Order of Exclusion for a staff member. LPA Martinez with Alexandria Archangel and explained the purpose of today's visit.

LPA Martinez was informed by Alexandria Archangel, the staff member named in the Order of Exclusion, Edmond, Rahas L., no longer works at the facility.

LPA Martinez  provided Alexandria Archangel with a copy of the Order and explained that Edmond, Rahas L. is not allowed in the facility effective immediately. Edmond, Rahas L. last shift was November 1, 2023.

An exit interview was held, and a copy of this report and Immediate Exclusion letter were provided to the facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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