<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700629
Report Date: 04/26/2024
Date Signed: 04/26/2024 10:56:39 AM

Document Has Been Signed on 04/26/2024 10:56 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. 3FACILITY NUMBER:
392700629
ADMINISTRATOR/
DIRECTOR:
ALEXANDRA ARCHANGELFACILITY TYPE:
772
ADDRESS:1117 SOUTH GRANT STREETTELEPHONE:
(209) 330-7155
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 15CENSUS: 9DATE:
04/26/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Alex Archangel TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/26/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with 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 holds current certificate. The facility is licensed for fifteen ambulatory clients. There are currently nine clients who reside at this facility.

The LPA Martinez toured the facility with Alex Archangel on 04/26/2024 at 11:00 AM.

LPA Martinez reviewed five resident files and five staff files. All files were complete and maintained. LPA Martinez reviewed two medication administration records (MAR), and both MARs were maintained. The facility has a infection control plan and a natural emergency disaster plan. In addition, the facility has liability insurance and a surety bond. The last fire drill was on April 01, 2024, and fire extinguishers are in good repair. The first aid kit is complete and maintained. The facility bedrooms, common areas, kitchen, and laundry room are in furnished and sanitary. The facility has an adequate food supply.

Based on this annual inspection, the facility is in compliance with California Code of Regulations Title 22 and Health and Safety Code. There were no deficiencies cited at this time. 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: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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 1