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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093609114
Report Date: 04/26/2022
Date Signed: 04/26/2022 02:21:56 PM


Document Has Been Signed on 04/26/2022 02:21 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:PENN, KRISTINA LYNNFACILITY NUMBER:
093609114
ADMINISTRATOR:PENN, KRISTINA LYNNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 543-1212
CITY:SOUTH LAKE TAHOESTATE: CAZIP CODE:
96150
CAPACITY:14CENSUS: DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Kristina Lynn PennTIME COMPLETED:
02:50 PM
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On 04/26/2022 Licensing Program Analysts (LPAs) Arianna Manabat and Alize Tillery met with Licensee Kristina Lynn Penn for an unannounced annual / one year inspection. During the inspection there were six children in care. All individuals subject to criminal background review have obtained a criminal record clearance. Hours of operation are from 8:00am to 5:00pm weekdays, except for Thursday.

LPAs toured the one-story home at 1:00pm and a health and safety inspection was conducted in the areas accessible to children. The off-limits areas include the two sheds and the Master bedroom. LPAs observed that the home has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. LPAs observed all the required postings advised the licensee that, if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. LPAs did not observe a fireplace.

Licensee has provided documentation of current immunization records. Children's roster and a fire drill log were observed, the last fire drill was conducted on 03/21/2022. LPAs observed Licensee’s and Aide’s CPR/First aid card had an expiration date of August 2021. The Licensee Kristina Lynn Penn and Aide have Mandated Reporter trainings which expire August 2021 and June 2020. Licensee has stated that the CPR/First Aid and Mandated Reporter training are expired and that the physical files indicate the most recent training date. Licensee did not renew their CPR/First Aid training or Mandated Reporter training, due to this, two type B citations will be assessed to the facility.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Report continues on 809C................

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) -26-1414
LICENSING EVALUATOR NAME: Arianna ManabatTELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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 04/26/2022 02:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: PENN, KRISTINA LYNN
FACILITY NUMBER: 093609114

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as the Mandated Reporter training expired in August 2021 and June 2020 for both Licensee and Aide which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2022
Plan of Correction
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Licensee will send and provide an updated Mandated Reporter Training for both Licensee and Aide.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as the Licensee and Aide have a CPR which expires on August 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2022
Plan of Correction
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Licensee has agreed to provide Licensing Program Analyst Arianna Manabat with confirmation of a set appointment for the CPR and First Aid training.

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: Maria MayorgaTELEPHONE: (916) -26-1414
LICENSING EVALUATOR NAME: Arianna ManabatTELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: PENN, KRISTINA LYNN
FACILITY NUMBER: 093609114
VISIT DATE: 04/26/2022
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….... Continued from previous 809 page

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Exit interview conducted and report was reviewed with the Licensee Kristina Lynn Penn.

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) -26-1414
LICENSING EVALUATOR NAME: Arianna ManabatTELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC809 (FAS) - (06/04)
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