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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455406084
Report Date: 04/29/2019
Date Signed: 04/29/2019 10:19:48 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:SHASTA HEAD START - LAKE CENTERFACILITY NUMBER:
455406084
ADMINISTRATOR:SELLERS, L./GROVES, B.FACILITY TYPE:
850
ADDRESS:375 LAKE BLVD., SUITE 200TELEPHONE:
(530) 241-1036
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:88CENSUS: 55DATE:
04/29/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Heather StevensTIME COMPLETED:
10:30 AM
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A case management inspection was made to this facility by Licensing Program Analyst (LPA) Snow. LPA met with the Administrator, Heather Stevens. The facility had self-reported an incident in a timely manner that occurred on 3/27/19 at 12:20 pm. A sleeping child was being monitored when the child gasped and then stopped breathing for approx. 3-4 secs. Child started breathing again and staff continued to observe the child and called the parents who arrived and took the child for evaluation. The child now has an Incidental Medical Plan (IMS) for sleep apnea. This facility provides IMS. LPA reviewed storage of medication, equipment, supplies and reviewed children’s, personnel and administrative records.
The facility had also self-reported an incident in a timely manner that occurred on 3/26/19 at mealtime where two children had put their hands down the others pants. The children were being monitored at the time and reported to parents. The children no longer sit together and are monitored during meals and other table times. Staff reports no further incidents have occurred.

With the evidence provided in the incident report, the subsequent information obtained through interviews during the case management inspection by LPA Snow, it has determined no violations of Title 22 regulations occurred.

All licensing reports are public information and must be made available upon request for at least three years. This report was read and discussed with the Administrator.

Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime SnowTELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2019
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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