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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700629
Report Date: 09/13/2021
Date Signed: 09/13/2021 02:13:49 PM

Document Has Been Signed on 09/13/2021 02:13 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. 3FACILITY NUMBER:
392700629
ADMINISTRATOR:ALEXANDRA ARCHANGELFACILITY TYPE:
772
ADDRESS:1117 SOUTH GRANT STREETTELEPHONE:
(925) 570-3282
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 15CENSUS: 9DATE:
09/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:56 PM
MET WITH:C BensonTIME COMPLETED:
02:15 PM
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LPA Johnson arrived at the care facility and met with C. Benson to conduct a case management visit into an incident report received on 09/02/2021.

R-1 AWOL'd from the facility on 9//2/2021 at approximately 4:45 AM, Staff members contacted the Administrator and followed R1. The staff member lost sight of R1 and contacted Stockton Police. R1 did not return back to the facility and was discharged from the program after she was located.

According to R1's Physicians report, R1 is allowed to leave the facility unassisted.

No deficiencies were cited on today's date.

The Department has requested a new LIC 200 Form and the Board Resolution changing Velvit Turner to the CEO. If the facility is closing the department has requested a plan for closure.

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
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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