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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093617355
Report Date: 04/05/2023
Date Signed: 04/05/2023 12:24:24 PM


Document Has Been Signed on 04/05/2023 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:NORDBY, TRACY A.FACILITY NUMBER:
093617355
ADMINISTRATOR:NORDBY, TRACYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 919-6466
CITY:GEORGETOWNSTATE: CAZIP CODE:
95634
CAPACITY:14CENSUS: 12DATE:
04/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Tracy NordbyTIME COMPLETED:
12:40 PM
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On April 5th, 2023, Licensing Program Analyst (LPA) Soleil Marx met met with Licensee, Tracy Nordby, for an unannounced annual / one year inspection. During the inspection there was a census of 12 children in care being supervised by the licensee and an assistant. Facilities hours of operation are Monday through Friday, 7:00 AM-5:30 PM.

A health and safety inspection was conducted in the areas accessible to children. The off-limits areas include: Backyard, Downstairs basement, all bedrooms, kitchen, and decking. 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 home was safe, orderly, and free of hazards. 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. The fireplace in the home is appropriately barricaded to meet reg. Licensee stated there are no firearms on the premises. There is a pool on the premises, in the off-limits backyard, that is properly fenced to meet regulations. The fencing does not obscure the pool from view, has a gate that swings away from the pool, self-closes and has a self-latching device.

LPA observed a children's roster and fire drill log, the last fire drill was conducted 02/10/2023. Licensee's has current CPR/First aid, which expires 03/2024, and Licensee and assistant have current Mandated Reporter Training. 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 DunawayTELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil MarxTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: NORDBY, TRACY A.
FACILITY NUMBER: 093617355
VISIT DATE: 04/05/2023
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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.

LPA discussed safe sleep regulations with the Licensee.

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 DunawayTELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil MarxTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC809 (FAS) - (06/04)
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