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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700752
Report Date: 10/18/2021
Date Signed: 10/18/2021 12:22:52 PM

Document Has Been Signed on 10/18/2021 12:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: 28DATE:
10/18/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Alexandria ArchangelTIME COMPLETED:
12:30 PM
NARRATIVE
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On 10/18/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced case management visit to follow up on documents that had previously been requested and unfulfilled. At approximately 11:50 AM, LPA met with Program Director, Alexandria Archangel and explained the purpose of the visit.

Based on information provided, on 09/23/2021 the Regional Manager (RM) of the Sacramento South Community Care Licensing Division (CCLD) requested documentation showing the name of the acting Chief Executive Officer (CEO) and the names of the Board of Directors. The RM further requested that if the Board does not appoint and provide a CEO, all board members would need a background clearance as the Board would be considered as having operational control. These documents were to be submitted to the Regional Office by the close of business day Monday, September 27, 2021. An extension was granted to provide the requested documents by 10/04/2021. On 10/06/2021 and 10/12/2021, the RM followed up via email as a result of the non-submitted requested documents. The documents requested by the RM were the LIC200 and LIC308 for each facility that is currently licensed, signed by the CEO or acting CEO designated by the Board. In addition, CCLD requested the names and titles of the board members.

As of the date of this visit, CCLD did not receive the requested documents.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted with the Program Director. A copy of the report and Appeal Rights were given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2021
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 2
Document Has Been Signed on 10/18/2021 12:22 PM - It Cannot Be Edited


Created By: Mohamed Filouane On 10/18/2021 at 11:18 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2021
Section Cited
CCR
80061(a)

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Reporting Requirements
Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.
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The Licensee shall submit the requested documents to the Department.
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This requirement has not been met as evidenced by: the Licensee failed to provide the requested documents to the Department after receiving an extension.
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Type B
10/18/2021
Section Cited
ILS80061(e)

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Reporting Requirements
Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section.
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The Licensee shall submit the requested documents to the Department.
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This requirement has not been met as evidenced by: the Licensee failed to provide the requested documents to the Department after receiving an extension.
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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Mohamed Filouane
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2021


LIC809 (FAS) - (06/04)
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