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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005358
Report Date: 09/20/2024
Date Signed: 09/20/2024 01:19:52 PM

Document Has Been Signed on 09/20/2024 01:19 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:AMERICAN RIVER RESIDENTIAL SERVICESFACILITY NUMBER:
347005358
ADMINISTRATOR/
DIRECTOR:		SHAWNA VALVERDEFACILITY TYPE:
735
ADDRESS:4741 ENGLE ROADTELEPHONE:
(916) 483-8424
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 28CENSUS: 25DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Zachary SpainTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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On 9/20/2024, Licensing Program Analysts (LPAs) Cassie Yang and Cassie Mikkelson arrived unannounced at the facility to conduct a required annual inspection utilizing the care tool. LPAs met with Administrator Zachary Spain and explained the purpose of the visit.

LPAs and Administrator conducted a tour of the interior and exterior of the facility to ensure the health and safety of clients in care. Areas toured included but not limited to: nine clients bedrooms, two spa rooms, laundry room, laundry room, medication room, recreational room, the bistro, backyard and the common areas. In areas toured, no immediate health, safety and/or personal rights violation observed.

File review conducted for five clients and five staff. LPAs observed the required documents present.

LPAs and Administrator discussed Administrator's certificate. Based on CCLD website,
SPAIN, ZACHARY #6001243735 is active, effective date of 07/08/2024 to 10/02/2026

Full care tool was completed, and facility is in substantial compliance.

Exit interview conducted and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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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