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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313621931
Report Date: 08/01/2023
Date Signed: 08/01/2023 11:48:09 AM


Document Has Been Signed on 08/01/2023 11:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:BOYS & GIRLS CLUB OF NORTH LAKE TAHOE - GREATFACILITY NUMBER:
313621931
ADMINISTRATOR:PEBORGH, LORELEI VANFACILITY TYPE:
850
ADDRESS:8125 STEELHEAD AVE, BLDG BTELEPHONE:
(530) 582-3760
CITY:KINGS BEACHSTATE: CAZIP CODE:
96143
CAPACITY:24CENSUS: 14DATE:
08/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lorelei Van PeborghTIME COMPLETED:
12:00 PM
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At approximately 10:00am, Licensing Program Analyst (LPA) Matthew Gallo met with Director Lorelei Van Peborgh for the purpose of an unannounced annual random inspection. Census included 14 preschool children supervised by 2 staff. Facility hours of operation are 8:00am-4:00pm, M-F, year round.

LPA toured the building including all activity and classroom spaces, restrooms, food service and outdoor play areas. All necessary postings were observed. Director stated there were no poisons or firearms on the premises, and LPA did not observe any bodies of water. All toxic and hazardous items were inaccessible to children. Functional carbon monoxide detector and smoke detector were present. Furniture and equipment were in good condition and floors appeared clean throughout the facility. Playground equipment and surfaces were free of loose or sharp parts, and the areas underneath or around climbing equipment were sufficiently cushioned with wood chips. Program provides breakfast, lunch, and snack, and menus were posted in visible sight. The food preparation space was free of litter and all food was protected against contamination. Storage containers with solid waste had tight-fitting covers. Drinking water was readily available to children both indoors and outdoors. LPA observed full legal signatures while reviewing the sign in and sign out sheet. Medication was properly stored and inaccessible to children. Sufficient napping equipment was available.

Staff and children's records were reviewed and observed to be complete. Review of staff records confirmed at least one staff member present today has current Pediatric CPR and First Aid certification, and that all staff currently employed with the facility have valid AB1207 Manded Reporter Training certificates. Criminal record clearances were also verified, and facility representative was reminded that all adults 18 and over, 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 Child Care Center. 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 Continued on 809-C

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2023
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BOYS & GIRLS CLUB OF NORTH LAKE TAHOE - GREAT
FACILITY NUMBER: 313621931
VISIT DATE: 08/01/2023
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LPA reviewed the Department's inspection authority and discussed with designee any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within 10 working days.

LPA discussed Assembly Bill 2370, which required licensed Child Care facilities to test their water for excessive amounts of lead, and confirmed facility is in compliance. LPA reminded licensee that testing must be conducted every five years from initial testing.

Director was encouraged to the visit the departments website at WWW.CCLD.CA.GOV for information regarding childcare updates, forms, regulations and legislation pertaining child care centers.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided an updated Plan of Operation that includes 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


No deficiencies were cited during today’s inspection.


Exit interview conducted and report was reviewed with the facility representative Lorelei Van Peborgh. Appeal rights and a Notice of Site Visit were provided, the latter of which must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Matthew GalloTELEPHONE: (916) 208-3734
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC809 (FAS) - (06/04)
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