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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 290317248
Report Date: 08/26/2021
Date Signed: 08/26/2021 11:46:39 AM

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:TAHOE FOREST CHILDREN'S CENTERFACILITY NUMBER:
290317248
ADMINISTRATOR:SHURTLEFF, MARILYN REBEKAHFACILITY TYPE:
830
ADDRESS:10121 PINE AVENUETELEPHONE:
(530) 582-3572
CITY:TRUCKEESTATE: CAZIP CODE:
96161
CAPACITY:36CENSUS: 21DATE:
08/26/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Rebekah Shurtleff - DirectorTIME COMPLETED:
12:00 PM
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On Thursday, August 26th, 2021, at 10:17am, Licensing Program Analyst (LPA) Blake Morillas conducted a Case Management Visit in regards to a received Unusual Incident Report (UIR). At 10:18am, a headcount of the Infant/Toddler program was conducted with 21 infant/toddlers and 6 staff being observed in separate rooms.

The Director self reported a incident which occurred on 8-19-2021 where a toddler was exiting the sandbox area of the outdoor area, stepped on a toy truck, slipped, and sustained a fractured femur.

At 10:31am, LPA conducted interviews of the Director and the staff who were present during said incident and the area where the incident occurred was also inspected.

After interviews conducted and observations made, It was determined that no Title 22 violations had happened.

At 11:40am, the report was reviewed with the Director and an exit interview was conducted.

Notice of site visit to be posted for 30 days.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Blake MorillasTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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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