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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057000034
Report Date: 10/19/2022
Date Signed: 10/19/2022 02:20:11 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/19/2022 02:20 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 AND CALAVERAS, THEFACILITY NUMBER:
057000034
ADMINISTRATOR:KARYN GREGORIUSFACILITY TYPE:
775
ADDRESS:153 BELLVIEWTELEPHONE:
(209) 754-4001
CITY:SAN ANDREASSTATE: CAZIP CODE:
95249
CAPACITY: 40CENSUS: 30DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ericka Beltran, Program DirectorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Renee Campbell made an unannounced visit to the facility on this day for the purpose of conducting a Required - 1 Year evaluation. LPA arrived at 11:30 AM and met with Ericka Beltran, Program Director (PD).

At 11:50 AM, LPA toured the facility with PD Beltran. LPA inspected food services. Clients provide their own lunches but facility does have plan in place for meals if needed. LPA observed First Aid storage. Bathrooms were inspected. Hot water was measured in 1 client bathroom used for screening purposes at 111 degrees F. Hand washing areas were clean and in good repair. Fire extinguishers were mounted and charged, with a last inspection date of 10/03/2022. The last fire drill was conducted on 09/19/2022..

LPA observed clients participating in activities such as computers, dancing,cleaning and arts and crafts. There were enough staff on hand to meet the needs of the clients present.

At 12:00 PM LPA requested to review 5 client files. LPA reviewed but not limited to the following items: Physician's report, TB test, Admission's agreement, IPP and Individual Services Plans and presence of Personal Rights statement..

At 1:00 PM LPA reviewed 3 staff files. LPA confirmed criminal record clearance and reviewed training records, physician's report and TB with no concerns noted

Based on the observations of the LPA, the facility appears to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with PD Beltran and a copy of this report along with advisory note was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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