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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057000034
Report Date: 09/26/2023
Date Signed: 09/26/2023 01:00:56 PM

Document Has Been Signed on 09/26/2023 01:00 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
SACRAMENTO AC/SC, 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: 49DATE:
09/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ericka Beltran, Director of ServicesTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct a case management visit to follow up on the incident report received 08/29/23. LPA Campbell met with administrator Ericka Beltran and explained the purpose of the visit.

LPA Campbell reviewed the incident report dated 08/29/23 regarding C1, who texted that they were going to shoot someone. The recipient of the text contacted law enforcement and C1 was suspended from day program. According to the administrator, the Sheriff’s office was unable to provide a copy of the police report.

When the Service Coordinator (SC) was contacted, it was reported that C1 had made inappropriate comments on 08/03/23 and was suspended at that time as well. The SC had therefore referred C1 to a yet to be selected behavior management program.

S1 was interviewed by LPA Campbell and reported that staff had participated in Crises Prevention classes. LPA Campbell observed the training course material binder which included training for the Emergency Response Plan, Challenging Behaviors and the Safety Manual.

LPA Campbell observed team meeting notes regarding C1’s behavior, Training Curriculum Guide for the year, the Evacuation Drill Record for 08/11/23, and Active Shooter Situation Preparedness and discussed the Early Warning Signs Checklist with the administrator.

No deficiencies issued during this visit.

Exit interview conducted with Ericka Beltran and a copy of this report was provided.

SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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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