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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 037000102
Report Date: 09/19/2023
Date Signed: 09/19/2023 11:18:04 AM

Document Has Been Signed on 09/19/2023 11:18 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: 42DATE:
09/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Karyn GregoriusTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived to the Day Program unannounced to conduct a Required Annual Visit. LPA met with Administrator Karyn Gregorius, and explained the purpose of the visit.

LPA Valerio and Administrator toured the physical plant to ensure compliance with Title 22 regulations. LPA observed 6 classrooms, common areas, 2 bathrooms, and the office area. Classrooms were observed to have necessary furniture, organized, and free from obstructions of any emergency exits. The facility currently does not provide any medications to participants. A first aid kit was observed. Sharps and cleaning supplies were observed to be locked away and inaccessible to participants. The exterior plant was observed to be free from debris. The exterior area has a shaded area for outdoor activities, a garden area, and a shed, which was observed to be locked due to holding chemicals and other storage items. The program has six (6) transport vans and were observed to be in working condition. The facility temperature thermostat provided a reading of 73*degrees F. Hot water was measured in the bathrooms at 106.3*F, which is within compliance of Title 22 regulations. LPA observed multiple fire extinguishers in the hallway and a pull alarm system. No health or safety concerns were observed during the visit. During the visit, staff were observed interacting with participants, completing paperwork, and leading class activities. Participants appeared to be engaged, happy, and socializing with peers.

LPA reviewed resident and staff files. Staff files were observed to be complete with up to date training for 2023. Resident files were observed to have necessary documentation for program and emergency information. The facility has an emergency disaster plan and an infection control plan. Staff interviewed were fully aware of the procedures in the event of an emergency.

LPA was provided with annual documentation prior to visit. An updated LIC 500 was obtained during the visit.

Per California Code of Regulations, Title 22, Division 6, Chapter 3, no deficiencies were observed during this visit. An exit interview was held with Administrator Karyn, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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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