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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293623581
Report Date: 06/02/2020
Date Signed: 06/02/2020 03:32:26 PM

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:LITTLE GEMSFACILITY NUMBER:
293623581
ADMINISTRATOR:SIMON, JAIMEFACILITY TYPE:
850
ADDRESS:908 NORTHSTAR DRIVETELEPHONE:
(530) 448-4522
CITY:TRUCKEESTATE: CAZIP CODE:
96161
CAPACITY:30CENSUS: 0DATE:
06/02/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jamie Simon and Lauren BelloTIME COMPLETED:
03:30 PM
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Application Specialist (AS) Seychelle De Luca met with Applicant Jamie Simon and President Lauren Bello for the purpose of a second announced prelicensing change of location tele-inspection (due to COVID-19). AS verified that Preschool classroom 2 has been cleared out and set up. Applicant and President stated they are not going to use Preschool classroom 3. Preschool classroom 3 is inaccessible to the children in care by a closed door with a latch. Without Preschool classroom 3, the total indoor space is 1535.695 square feet, which accommodates the requested capacity. Prior to today, Applicant Jamie Simon submitted proof 12 more napping cots have been ordered and sent AS an updated waiver request. AS verified the 12 extra cots arrived to the facility.

AS emailed a copy of the 809 to Applicant and President. Applicant and President understand they must open the email to send back an acknowledgement of receipt.

AS is issuing a provisional license that will expire 8/31/2020. Applicant and President acknowledge that the items listed below must be sent in and approved prior to the expiration date. Applicant and President understand the provisional license will not extended.

THE FOLLOWING ITEMS MUST BE SENT IN PRIOR TO EXPIRATION OF THE PROVISIONAL LICENSE:


1. Mail in an updated application with original signature.
2. Submit an updated Designation of Facility Responsibility (LIC 308), Monthly Operating Statement (LIC 401), Personnel Report (LIC 500), Job Descriptions, Personnel Policies, In-Service Training, and list of furniture and equipment.
3. Submit Incidental Medical Services Plan of Operation.
4. Submit Applicant Jamie Simon's and Director Andorra Fierro's paperwork.
5. A final review of the file by LPM Keven Peters.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De LucaTELEPHONE: (916) 217-4316
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2020
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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