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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093621202
Report Date: 07/28/2023
Date Signed: 07/28/2023 01:23:19 PM


Document Has Been Signed on 07/28/2023 01:23 PM - 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:APPLESEEDS ACADEMYFACILITY NUMBER:
093621202
ADMINISTRATOR:BALJIT KAURFACILITY TYPE:
850
ADDRESS:1100 LYONS AVE C1 + C3TELEPHONE:
(530) 208-8216
CITY:SOUTH LAKE TAHOESTATE: CAZIP CODE:
96150
CAPACITY:46CENSUS: 27DATE:
07/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Leigh Ellen YarbroughTIME COMPLETED:
01:30 PM
NARRATIVE
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On July 28th, 2023 Licensing Program Analyst (LPA) Soleil Marx met with Director, Leigh Ellen Yarbrough, for a case management inspection. Today's census included 15 preschool age children and 12 school age children above age 6 in care with five staff.

LPA discovered that a child was left alone in the outside playground with no staff supervision for approximately five minutes. Due to the fact that this incident was an absence of supervision, the incident should have been reported to the LPA or Sacramento Regional Office within 24 hours of the incident occurring.

Case carrying LPA did not receive any communication or an Unusual Incident Report regarding the incident from the facility. Director stated they did not know they needed to report the incident to licensing within 24 hours, they were only aware of needing to report physical injuries/medical emergencies. Not informing LPA or Regional Office within 24 hours of a child absence that threatens the physical or emotional health or safety of any child, is a violation of reporting requirements.

Title 22 deficiencies are cited on 809-D

Report reviewed with Director, exit interview conducted, appeal rights provided. Notice of Site Visit was provided and must remain posted for 30 days.
SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil MarxTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
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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Document Has Been Signed on 07/28/2023 01:23 PM - It Cannot Be Edited

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: APPLESEEDS ACADEMY
FACILITY NUMBER: 093621202

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2023
Section Cited
CCR
101212(d)(1)(C)

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(d) , a report shall be made to the Department by telephone or fax within the Department's next working day
(1) Events reported shall include the following:(C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
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Director submitted Unusual Incident Report to LPA.

POC cleared during visit by LPA Marx
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This requirement was not met as evidenced by:
Based on record review, LPA/SAC RO was not notified or sent UIR within 24 hours following an absence of supervision, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil MarxTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2023
LIC809 (FAS) - (06/04)
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