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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700752
Report Date: 07/23/2025
Date Signed: 07/23/2025 11:03:06 AM

Document Has Been Signed on 07/23/2025 11:03 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/
DIRECTOR:		ANTHONY ISBELLFACILITY TYPE:
735
ADDRESS:404-408 E. PINE STTELEPHONE:
(209) 330-7155
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 46CENSUS: 45DATE:
07/23/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:04 AM
MET WITH:Alex ArchangelTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Noel Wolf Petersen, arrived unanounced to conduct a case managment inspection at 8:00 am on 7/23/25. LPA met with Staff Gerardo verela and Adminitrator alexandria Archangel, and explained the purpose of the visit.

Physical Plant was inspected including but not limited to the kitchen, common areas, the client bedrooms, client bathrooms, exterior and evacuation route. the Facility is clean and the traffic areas are well lit and unobstructed. the Kitchen has lockable storage the sharps and toxics, as well as the 2 days of perishible/7days of non perishable food. The MARs are up to date and reflected accurately in kind and amount. the Common areas are in good repair, the clients have reasonable and privite access to an telephone and internet accessible device. the client bedrooms are in good repair, excepting bedroom 11. the administrator provided there is an active process of repair, no clients are allowed to stay in the room. Bathroom hardware is functional, water temperature is measured within the required range. The required posters: personal rights, federal work requirements, the facility sketch with evacuation routes, and ombudsman on the wall. The fire extinguishers are dated 7/2/25.

During a facility visit on 7/23/25 LPA observed, documented, and discussed with Alexandria Archangel the facilitys practice of reward tiers, which was deacribed as a level one or level 2 which allwd additional smoke breaks or freedom to leave the facility, including overnight passes if the clients particpates in group therapy sessions. these practices are not part of the facilites Plan of Operation and are a violation of a residents personal rights. Citations are issued on the 809D page related to this.

A copy of the appeal rights was given, a copy of the report was read and given to the administrator.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2025
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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Document Has Been Signed on 07/23/2025 11:03 AM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 07/23/2025 at 10:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: G.L.O.M. A.R.F. 6
FACILITY NUMBER: 392700752

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2025
Section Cited
CCR
85072(b)(6)

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85072 Personal Rights..(b)The licensee shall insure that each client is accorded the following personal rights...(6) To possess and use his/her own personal items, including his/her own toilet articles.
This requirement was not met as evidenced by:
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The Administrator will confer with owners about a new set of policies for reward and submit and addendum to program design detailing them by the poc date aug 20 2525
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record reviews of passdown and interviews with the clients and staff about the practices of additional smoke breaks being leveraged as a reward.

Which poses a potential risk to the health saftey or violation of clients rights in care.
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Type B
08/06/2025
Section Cited
CCR80072(6)

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80072 Personal rights: (6) To leave or depart the facility at any time.

This requirement was not met as evidenced by:
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The Administrator will confer with owners about a new set of policies for reward and submit and addendum to program design detailing them by the poc date aug 20 2525
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record reviews of passdown and interviews with the clients and staff about the practices of addional family visitation overnight passes being leveraged as a reward.

Which poses a potential risk to the health saftey or violation of clients rights in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2025


LIC809 (FAS) - (06/04)
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