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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343621414
Report Date: 05/30/2023
Date Signed: 05/30/2023 11:03:00 AM


Document Has Been Signed on 05/30/2023 11:03 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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:TOTS OF LOVE - ELK GROVE WESTFACILITY NUMBER:
343621414
ADMINISTRATOR:WILLIAMS, COURTNEYFACILITY TYPE:
850
ADDRESS:3151 DWIGHT ROAD, SUITE 400TELEPHONE:
(916) 689-8687
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:37CENSUS: 8DATE:
05/30/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Sreeparna Bhaumik TIME COMPLETED:
09:39 AM
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On 05/30/2023, Licensing Program Analyst Katy Maestas (LPA) and Licensing Program Manager Chayntel Hunter (LPM) arrived at the facility to conduct an unannounced Plan of Correction (POC) Inspection. Upon arrival, LPA and LPM disclosed the purpose of the inspection and were granted entrance into the facility. LPA and LPM met with Site Supervisor Sreeparna Bhaumik (S1). LPA and LPM toured the facility and observed 8 children being supervised by 3 staff members. LPA accessed Guardian to determine that all required adults were background cleared.

During the field visit, LPA and LPM spoke with Licensee Representative Courtney Williams (L1) via telephone to discuss today's report. During the phone conversation, L1 requested that S1 be designated as the Director of Record for the facility. LPA provided S1 with the list of requirements for the Directors Packet to be submitted to the Department. Once LPA receives all the required documentation, the Director of Record will be changed.

During a field visit conducted on 05/11/2023, a deficiency was issued for not reporting an unusual incident. The facility had a pipe burst on 03/14/2023 which resulted in water damage and a temporary closure of the facility, from 03/14/2023 until 05/02/2023, for repairs to be made. This unusual incident was not reported to the Department. The plan of correction (POC) due date was 05/18/2023; however, the POC was not received by the Department.

As of 05/30/2023, neither the LIC 624A Unusual Incident Report nor the Signed Statement described in the POC have been received by LPA. The Director did not correct the previously cited deficiency, which results in the amount of $1200 Civil Penalty for the period of 05/19/2023 to 05/30/2023.

An exit interview was conducted and the report was reviewed with S1. LPA provided S1 with Licensee Appeal Rights. A Notice of Site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Nola MaestasTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023
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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