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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 037000102
Report Date: 10/14/2021
Date Signed: 10/14/2021 04:54:53 PM

Document Has Been Signed on 10/14/2021 04:54 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:ARC OF AMADOR/CALAVERASFACILITY NUMBER:
037000102
ADMINISTRATOR:KARYN GREGORIUSFACILITY TYPE:
775
ADDRESS:75 ACADEMY DRIVETELEPHONE:
(209) 267-5978
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY: 45CENSUS: 16DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Karyn Gregorius, Executive DirectorTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) T. White arrived unannounced on this day for the purpose of conducting a required 1-year annual inspection. LPA arrived at 1:20 PM and met with Executive Director (ED), Karyn Gregorius. Present at the facility on this day was 16 clients and 10 staff.

At 1:35 PM, LPA toured the facility with ED Gregorius and inspected food services. Clients provide their own lunches but facility does have a plan in place for meals if needed. LPA observed facility does not manage medications. LPA inspected isolation room, which was clean and odor free. Bathroom was inspected and hand washing areas were clean. Hot water was measured in clients shared bathrooms at 119.3 and 118.4 degrees F. Temperature measured at 72 degrees Fahrenheit. ED stated facility reopened 09/13/2021. Fire extinguisher was last inspected on 09/28/2021. LPA observed mitigation plan completed. Facility has a 30 day supply of Person Protective Equipment (PPE) available. LPA observed smoke detector and carbon monoxide in operating condition during inspection. Fire drill was last conducted on 09/28/2021. Emergency Disaster plan updated on 10/01/2021. LPA reviewed 2 clients and 2 staff members files.

During inspection, LPA observed clients practicing social distancing.

LPA collected the following documents:
LIC 500- Personnel Report
LIC 308 - Designation of Facility Responsibility
LIC 610D - Emergency Disaster Plan

No deficiencies cited during inspection. Exit interview conducted with ED and a copy of report given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Treana White
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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