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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 057000034
Report Date: 10/11/2023
Date Signed: 10/11/2023 10:46:26 AM

Document Has Been Signed on 10/11/2023 10:46 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 AND CALAVERAS, THEFACILITY NUMBER:
057000034
ADMINISTRATOR:KARYN GREGORIUSFACILITY TYPE:
775
ADDRESS:153 BELLVIEWTELEPHONE:
(209) 754-4001
CITY:SAN ANDREASSTATE: CAZIP CODE:
95249
CAPACITY: 40CENSUS: 27DATE:
10/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Ericka Beltran - Program DirectorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required one year annual inspection visit. LPA met with Program Director (PD) and explained purpose of visit.

LPA toured the facility with PD. 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 at 114.2 degrees F in kitchen sink. Hand washing areas were clean and in good repair. Fire extinguishers were last inspected on . The last fire drill was conducted on .

LPA observed clients participating in activities such as computers, karaoke, check-in, discussing Halloween, and arts and crafts. There were enough staff on hand to meet the needs of the clients present.

LPA reviewed four staff and five client files. Resident emergency contact complete. LPA observed all staff and client files complete. All staff have criminal record clearance and are associated to the facility.
 
LPA received the following updated documentation on today's date: LIC 308 Designation of administrator and LIC 610-D Emergency Disaster Plan.

Per the California Code of Regulations, Title 22 no deficiencies were observed or cited. 

Exit interview held with Administrator. A report and LIC 811 (Confidential Names) was left at the facility
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
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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