392700752-1-12-2026-27-AS-NWPN-DQ9PVN-20260112103921

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700752
Report Date: 12/26/2025
Date Signed: 01/12/2026 10:39:55 AM

Document Has Been Signed on 01/12/2026 10:39 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. 6		FACILITY NUMBER:	392700752
ADMINISTRATOR/ DIRECTOR:	ALEXANDRIA ARCHANGEL		FACILITY TYPE:	735
ADDRESS:	404-408 E. PINE ST		TELEPHONE:	(209) 330-7155
CITY:	LODI	STATE: CA	ZIP CODE:	95240
CAPACITY: 46		CENSUS: 45	DATE:	12/26/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Joanni Rincon		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

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	Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced, 12/26/2025 9:15am to the facility to conduct an annual inspection, LPA met with facility managers Geraldo Varela and Joanni Rincon, and later Administrator Alex Archangel by phone explained the purpose of the visit. GLOM ARF 6 is an adult residential facility for adults aged 18-59, there are 45 amublatory, 0 nonambulatory, and 0 bedridden residents. 0 residents have a restricted care condition at the time of the inspection, 6 clients have insulin dependant diabetes, controlled under their own power. Physical Plant was inspected, including the kitchen, bedrooms, bathrooms, common areas, storage areas, exteriors, and evacuation routes. Facility is clean, traffic areas are unobstructed and well lit. Kitchen has adequate food stored for 2 days perishable, 7 days non perishable, LPA notes some undated chopped veg in the fridge, and a quart of heavy cream expiring tomorrow. LPA gave guidance to do a quarterly inventory for dust/bulges/dents/dates of the canned goods and keep a date on everything possible to prevent the possibility of serving expired foods. Kitchen has adequate lockable storage for sharps and toxics, such that no chemicals are dripping onto sharps used for food prep. Medication for 5 clients was checked against an electronic mars. Medications and mars match. Refusal documentation process is adequately detailed to provide reason, PRN documentation process is adequatedly detailed to provide reason and result, Medication destruction record has double signatory space. LPA gave guidance that if a drug arrives from the pharmacy, not in the condition it was expected, that should be documented in a general note. LPA gave guidance that if a mediction is being repeatedly refused that the perscribing doctor be looped into a discussion about if that care could be staged down, and vice versa if a PRN is being repeatedly given the percribing doctor be looped into a discussion if that care could be staged up. Continued on C page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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. 6	FACILITY NUMBER: 392700752
	VISIT DATE: 12/26/2025

NARRATIVE

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4 of 30 checked Bedrooms have required furniture, including mattress encasements.

2 of 13 checked bathrooms(7 are full bath,6 are half bath) have hardware in good repair, one bathroom is out of repair, it has an active work order as of 12/26/2025.

Common areas have furniture in good repair, exteriors are clean and free of trip hazards and have space for activities. Evacuation route gate at the rear swings freely and latches closed, and while not accessible to a wheelchair the facility is entirely ambulatory residents. LPA notes the shortest path to the assembly point from any exterior door is open and ungated.

5 client files were reviewed for the signed admission agreements, needs and services plans, recent medical assessments both mental and physical, and behavioral notes. documents are present and up to date.

2 clients p+I were checked against the held cash at random, they were found to be in agreement.

5 staff files were reviewed for the recent and initial trainings, in relevant topics for the required times, the criminal backround and fingerprinting, and guardian association.

Administrator files, Workers comp and the control of property(via lease, statements, or otherwise) to be turned in to the LPA via email, by end of day monday 12/29/2025. noel.wolfpetetersen@dss.ca.gov. Other administrator files were reviewed including required posters, infection control plan, evacuation control plan, administrator certificate, facility sketch and facilility licence are up to date and present. sureity bond is 7500 which seems slightly low for the facility of this size, LPA asked the staff to perform an audit and ensure the bonded amount is at least 1000$ above whatever amount the facility is holding.

Only five of 45 clients are not attending program today, 1 was interviewed. 3 staff were interviewed. A copy of the report was read and given to the facility manager, no citations given.

Exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2025

LIC809 (FAS) - (06/04)

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