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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 037000102
Report Date: 10/12/2022
Date Signed: 10/12/2022 11:58:49 AM

Document Has Been Signed on 10/12/2022 11:58 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
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: 20DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Karyn GregorgiusTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to conduct the annual inspection. LPA Valerio confirmed with staff that there are zero participants or staff at the program that have experienced any signs or symptoms of COVID-19 in the last 10 days.

LPA and Administrator Karyn toured the facility to ensure compliance with Title 22 regulations. LPA also conducted the infection control tool. The facility has a Infection Control Plan on file which meets department regulations. Day Program staff (12) were observed to be wearing mask, engaging with participants, and conducting in-person and virtual services. LPA observed the hot water to be at 118.2*F in both bathrooms. The temperature inside the facility was 72*F. The facility had participants separated into groups, had tables spaced well over 6 feet distance, and items were organized in all areas. Common area were clean and had hand sanitizer for use. No emergency exits were obstructed. The program does not have participants that take medications on site and participants bring there own lunches. The program has a designated isolation room.

LPA obtained the following documentation for the facility file: LIC 500

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was held with Administrator Karyn, and a copy of the report was given.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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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