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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700629
Report Date: 12/10/2024
Date Signed: 12/10/2024 09:42:12 AM

Document Has Been Signed on 12/10/2024 09:42 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: 12DATE:
12/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Awanda BrownleeTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Kesha Lewis arrived at this facility unannounced on 12/10/2024 at 8:30 AM to conduct a case management visit. LPA Lewis met with staff and spoke to Karen Edmond on the phone and explained the purpose of the visit.

The Purpose of the visit was to review and incident report the was sent to the department on 10/17/2024 regarding an incident that took place on 10/16/2024. R1 A.W.A.L'ED from the facility. During 15 minute room checks R1 was found to not be in their room staff searched the surrounding area but could not locate R1. R1'S physicians report states they are able to leave the facility unassisted.

No deficiencies are being cited during todays visit.


Exit interview was held, and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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