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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093604118
Report Date: 01/19/2023
Date Signed: 01/19/2023 12:37:28 PM

Document Has Been Signed on 01/19/2023 12:37 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:HEAVENLY SKI RESORTFACILITY NUMBER:
093604118
ADMINISTRATOR:SIMSPSON, CASSIDYFACILITY TYPE:
850
ADDRESS:3860 SADDLE ROADTELEPHONE:
(530) 542-6912
CITY:SOUTH LAKE TAHOESTATE: CAZIP CODE:
96150
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 20DATE:
01/19/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Cassidy SimpsonTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Soleil Marx and Jeremey McClain met with Director Cassidy Simpson to conduct an unannounced case management inspection regarding lead testing. During today's inspection there was a census of 20 children being supervised by 4 teachers. The purpose of today's inspection was to create a plan of correction following reports of lead exceedance in two of the facility outlets.

On 11/4/2022, the facility tested water samples for lead. The Lead Testing identified two water outlets that has a Lead Exceedance over the amount of 5.5ppb. The water outlet sampled is marked B, which has an exceedance of 7.9ppb and C which has an exceedance of 7.6ppb.

Usage of the faucets was stopped immediately upon receiving the results, and a Primo water station is now being used a source for water. The facility also has alternate water outlets. The facility will retest before using water outlets sampled B and C, and will follow up with LPA prior to use.



Deficiencies are cited on the subsequent page of the report and are considered a potential threat to the health and safety of children in care, if not corrected.

An exit interview was conducted with the Director. LPA provided Director with Appeal Rights, and a Notice of Site Visit that must be posted for 30 days.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Soleil Marx
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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Document Has Been Signed on 01/19/2023 12:37 PM - It Cannot Be Edited


Created By: Soleil Marx On 01/19/2023 at 11:33 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: HEAVENLY SKI RESORT
FACILITY NUMBER: 093604118

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2023
Section Cited

101700.3(b)(1)

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California Lead Action Level at Child Care Centers (b) Testing results with ... (1) A ... values of 5.5 ppb or greater shall be deemed an Action Level Exceedance. This requirement is not met as evidenced by:
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Usage of the faucets was stopped immediately upon receiving the results.Facility will use primo water station and other water outlets for sources of water. Director stated management is coming to turn off the water pipes to make water outlets inoperable.
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Based on record review, two water outlets tested exceeded the allowed 5.5 ppb, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Director will send LPA video of sink in inoperable condition.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Natalie Dunaway
LICENSING EVALUATOR NAME:Soleil Marx
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023


LIC809 (FAS) - (06/04)
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