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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093624376
Report Date: 10/06/2023
Date Signed: 10/06/2023 12:24:42 PM

Document Has Been Signed on 10/06/2023 12:24 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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LTUSD INFANT PROGRAMFACILITY NUMBER:
093624376
ADMINISTRATOR:SALAZAR, ANDREAFACILITY TYPE:
830
ADDRESS:1100 LYONS AVENUETELEPHONE:
(530) 541-2850
CITY:SOUTH LAKE TAHOESTATE: CAZIP CODE:
96150
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 6DATE:
10/06/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Amy LindstromTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Soleil Marx met with Facility Representative, Amy Lindstrom, for the purpose of an unannounced plan of correction inspection. LPA observed a census of six infants being supervised by three staff.

This facility was previously cited under CCR 101217(a) for not having staff files available for LPA to review at the time of inspection. During today's visit, LPA had access to review staff files electronically. LPA will clear the deficiency that was cited on 09/08/2023.

Report was reviewed with Facility Representative and exit interview was conducted. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Soleil Marx
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
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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