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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 093620107
Report Date: 05/10/2023
Date Signed: 05/10/2023 02:20:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2023 and conducted by Evaluator Amanda Sutter
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20230504150001
FACILITY NAME:LTUSD PRESCHOOL PROGRAMFACILITY NUMBER:
093620107
ADMINISTRATOR:LINDSTROM, AMYFACILITY TYPE:
850
ADDRESS:1100 LYONS AVENUETELEPHONE:
(530) 541-2850
CITY:SOUTH LAKE TAHOESTATE: CAZIP CODE:
96150
CAPACITY:20CENSUS: 18DATE:
05/10/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Amy LindstromTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Daycare child sustained fracture ankle while in care due to lack of supervision
INVESTIGATION FINDINGS:
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On Thursday, May 10, 2022, Licensing Program Analysts (LPAs) Soleil Marx and Amanda Sutter met with Director Amy Lindstrom to deliver findings regarding the above allegations. LPAs observed 18 children supervised by 4 staff. It was alleged that a daycare child sustained fracture ankle while in care due to lack of supervision.

Throughout the course of the investigation, LPAs conducted interviews and made observations. Through interview, LPAs learned that on the morning of May 4, a child fractured their tibia and fibia. At the time of the injury, there were 19 children supervised by 2 staff in the outdoor play space. Staff stated to LPAs that they found the child sitting below the playground structure, but that they did not witness the child falling. Director stated that they were situated in the middle of the playground near the two pirate ships, and Staff 1 (S1) stated that they were assisting children by the swings, leaving the side of the playground with the play structure without supervision. CONTINUED ON LIC9099-D
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 03-CC-20230504150001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: LTUSD PRESCHOOL PROGRAM
FACILITY NUMBER: 093620107
VISIT DATE: 05/10/2023
NARRATIVE
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Based on the evidence obtained, LPA determined that the allegation is substantiated, meaning that the preponderance of evidence standard has been met. One Title 22 Deficiencies has been issued on the attached LIC 809-D. The director was informed that this report dated 5/10/2023 documents one Type A citation which shall be posted for 30 consecutive days. The director shall also provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Licensee has been provided with appeal rights. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the director Amy Lindstrom.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2023 and conducted by Evaluator Amanda Sutter
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20230504150001

FACILITY NAME:LTUSD PRESCHOOL PROGRAMFACILITY NUMBER:
093620107
ADMINISTRATOR:LINDSTROM, AMYFACILITY TYPE:
850
ADDRESS:1100 LYONS AVENUETELEPHONE:
(530) 541-2850
CITY:SOUTH LAKE TAHOESTATE: CAZIP CODE:
96150
CAPACITY:20CENSUS: 18DATE:
05/10/2023
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Amy LindstromTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Playground structure is not safe for younger children
INVESTIGATION FINDINGS:
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On Thursday, May 10, 2022, Licensing Program Analysts (LPAs) Soleil Marx and Amanda Sutter met with Director Amy Lindstrom to deliver findings regarding the above allegations. LPAs observed 18 children supervised by 4 staff. It was alleged that the playground structure is not safe for younger children.

LPAs observed the playground structure noticed that the play structure does not have a manufacturer label. Therefore it could not be determined that the playground structure is not safe for younger children. The above allegation is determined to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove it. An exit interview was conducted. Appeal rights were discussed. A notice of site visit was provided and shall remain posted for 30 days.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 03-CC-20230504150001
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: LTUSD PRESCHOOL PROGRAM
FACILITY NUMBER: 093620107
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited
CCR
101229(a)(1)
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101229 Responsibility for Providing Care and Supervision (a)(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
This regulation was not met as evidenced by:
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Director stated that she and staff have decided to no longer use the swingset in order to increase visual observation for the entire playground area. Director to submit a written plan to LPA stating how the facility will improve supervision outdoors.
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Based on observation, LPAs learned that staff did not visually observe a child who broke their tibia and fibia, which poses an immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4