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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700752
Report Date: 11/02/2023
Date Signed: 11/02/2023 09:39:33 AM


Document Has Been Signed on 11/02/2023 09:39 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. 6FACILITY NUMBER:
392700752
ADMINISTRATOR:ANTHONY ISBELLFACILITY TYPE:
735
ADDRESS:404-408 E. PINE STTELEPHONE:
(209) 330-7155
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY:46CENSUS: 44DATE:
11/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Anthony IsbellTIME COMPLETED:
09:45 AM
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On November 02, 2023 At 9:30 AM, Licensing Program Analyst (LPA) Avelina Martinez  arrived unannounced to deliver an Order of Exclusion for a staff member. LPA Martinez with Anthony Isbell and explained the purpose of today's visit.

LPA Martinez was informed by Anthony Isbell, the staff member named in the Order of Exclusion, Edmond, Rahas L., does not works at the facility.

LPA Martinez  provided Anthony Isbell with a copy of the Order and explained that Edmond, Rahas L. is not allowed in the facility effective immediately.

An exit interview was held, and a copy of this report and Immediate Exclusion letter were provided to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
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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