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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700752
Report Date: 07/23/2021
Date Signed: 07/23/2021 03:31:48 PM

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: 46DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Anthony Isbell, AdministratorTIME COMPLETED:
11:05 AM
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On 07/23/2021 at 8:30am, Licensing Program Analyst (LPA) T. White spoke with Administrator, Anthony Isbell regarding facility risk assessment questions. Administrator confirmed no staff or clients have experienced symptoms within the last 10 days. At 9:20 am, LPA T. White arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Administrator, Anthony Isbell and Director, Peggy Phelps. LPA explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 46 ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and side yard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature for clients is maintained at 74 degree Fahrenheit. Hot water temperature in the shared clients’ bathroom was measured at 109.6 and 107.6 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. There is a minimum of 7-day non-perishable and 2-day perishables foods. LPA observed smoke detectors is interconnected with the fire department. LPA observed carbon monoxide in operating condition during inspection. Fire extinguisher was last serviced on January 07, 2021. LPA observed mitigation plan completed. First aid kit observed to be complete. Fire drill was last conducted on 07/14/2021.
The following forms to be updated and submitted to CCLD by 07/30/2021:
LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview conducted with Administrator, copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
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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