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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700752
Report Date: 02/22/2024
Date Signed: 02/23/2024 07:23:04 AM

Document Has Been Signed on 02/23/2024 07:23 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: 46DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Jessica Gutierrez and Alex ArchangelTIME COMPLETED:
01:00 PM
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On 02/22/2024 at 10:30 AM Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Jessica Gutierrez and Alex Archangel and explained the purpose of the visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current certificate and expires in 2026 The facility is licensed for forty-six ambulatory clients. There are currently forty-six clients who reside at this facility.

The LPA Martinez toured the facility with Jessica Gutierrez Cassandra Garcia on 02/22/2024 at 12:00 PM.

LPA Martinez reviewed five client files and five employee files during today's annual inspection. The client and resident files were maintained. LPA Martinez reviewed employee training records, infection control plan, emergency disaster plan, surety bond, fire inspection, and liability insurance documents.

The medication room is locked, and the Medication Administration Records (MARs) were complete. The facility has a first aid kit. The facility fire extinguishers were in good repair, and last inspection was on 02/04/2024. The facility's last Fire Drill 01/24/2024.

The facility was clean and furnished during today's inspection. Client bedrooms were sanitary and furnished. The facility bathrooms were sanitary and furnished. The exterior of the facility is clear of debris, and has a covered patio for client use. The facility laundry room is furnished and sanitary. The facility kitchen is sanitary, and the facility has an adequate food supply.

As a result of this visit, there were no deficiencies cited. An exit interview was conducted, and a copy of this 809 report was provided to the facility.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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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