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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093620107
Report Date: 05/10/2023
Date Signed: 05/10/2023 02:23:24 PM

Document Has Been Signed on 05/10/2023 02:23 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: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: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 18DATE:
05/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Amy LindstromTIME COMPLETED:
02:30 PM
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On May 10th, 2023 Licensing Program Analysts (LPA) Soleil Marx and Amanda Sutter met with Director, Amy Lindstrom, for a case management inspection. LPAs observed a census of 18 preschool age children being supervised by four staff.

It was discovered that a child sustained a serious injury in care on 05/04/2023, which resulted in the child's authorized representatives picking up the child early and taking the child in to the emergency room. An x-ray determined the injury to be a broken tibia and fibula. Due to the fact that the child's authorized representative sought medical treatment, the incident should have been reported to the LPA or Regional Office within 24 hours of the incident occurring.

LPA did not receive any communication or an Unusual Incident Report regarding the incident. Director stated they did not know they needed to report the incident to licensing within 24 hours and that they only reported it to the district. Not informing LPA or Regional Office of an incident which requires medical attention within 24 hours is a violation of reporting requirements.

Title 22 deficiencies are cited on 809-D

Report reviewed with Director, exit interview conducted, appeal rights provided. Notice of Site Visit was provided and must remain posted for 30 days.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Soleil Marx
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2023 02:23 PM - It Cannot Be Edited


Created By: Soleil Marx On 05/10/2023 at 01:47 PM
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: 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 B
05/17/2023
Section Cited
CCR
101212(d)(1)(B)

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101212 Reporting Requirements
(d) a report shall be made to the Department by telephone...within the...next working day.. (1) Events reported shall include (B) Any injury to any child that requires medical treatment.
The requirement was not met as evidenced by:
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LPA reviewed reporting requirements with Director. Director confirms she understands the reporting requirements and will submit an Unusual Incident Report for the incident to LPA by POC due date.
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Based on interview and record review the Director did not meet this requirement by not contacting LPA or regional office to report the incident regarding an injury that required medical attention, which poses a potential Health, Safety, and/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.
SUPERVISOR'S NAME:Natalie Dunaway
LICENSING EVALUATOR NAME:Soleil Marx
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


LIC809 (FAS) - (06/04)
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