093609114-4-12-2023-03-CC-SMAX-CQTRWV-20230412132346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 093609114
Report Date: 04/12/2023
Date Signed: 04/12/2023 01:23:52 PM

Document Has Been Signed on 04/12/2023 01:23 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:	PENN, KRISTINA LYNN		FACILITY NUMBER:	093609114
ADMINISTRATOR:	PENN, KRISTINA LYNN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(530) 543-1212
CITY:	SOUTH LAKE TAHOE	STATE: CA	ZIP CODE:	96150
CAPACITY:	14	CENSUS: 4	DATE:	04/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Kristina Lynn Penn		TIME COMPLETED:	01:35 PM

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On April 12th, 2023, Licensing Program Analyst (LPA) Soleil Marx met met with Licensee, Kristina Lynn Penn, for an unannounced annual / one year inspection. During the inspection there was a census of 4 children in care being supervised by the licensee. All individuals subject to criminal background review have obtained a criminal record clearance. Facilities hours of operation are 08:00AM to 05:00 PM weekdays, except Thursdays.

A health and safety inspection was conducted in the areas accessible to children. The off-limits areas include: Master bedroom and two sheds. Licensee understands that children may never enter these off-limits areas. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. LPA observed all required postings. LPA observed the home was safe, orderly, and free of hazards. LPA observed a variety of age appropriate toys available to children in care. LPA advised the licensee that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. Licensee stated there are no firearms or bodies of water on the premises.

LPA observed a children's roster and fire drill log, the last fire drill was conducted 01/20/2023. Licensee has current CPR/First aid, which expires 05/2024, and Licensee has current Mandated Reporter Training, which expires 05/2024 Licensee understands both CPR and mandated reporter training's’ must be completed every two years. LPAs reviewed records of children’s files and staff files, all which contained the required documentation. (1/2)

SUPERVISOR'S NAME: Natalie Dunaway	TELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil Marx	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: PENN, KRISTINA LYNN	FACILITY NUMBER: 093609114
	VISIT DATE: 04/12/2023

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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

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.

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.

No deficiencies were cited during today’s inspection.

Exit interview conducted and report was reviewed with the Licensee. A notice of site visit was provided and must remain posted for 30 days (2/2)

SUPERVISOR'S NAME: Natalie Dunaway	TELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil Marx	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

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