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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 292701027
Report Date: 04/25/2022
Date Signed: 04/25/2022 02:52:19 PM

Document Has Been Signed on 04/25/2022 02:52 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:TAHOE ABILITY PROGRAMFACILITY NUMBER:
292701027
ADMINISTRATOR:WHITINGTON,KIMBERLYFACILITY TYPE:
775
ADDRESS:11025 PIONEER TRAILTELEPHONE:
(417) 619-0713
CITY:TRUCKEESTATE: CAZIP CODE:
96161
CAPACITY: 30CENSUS: 15DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Mariah O'Shaughnessy, Program ManagerTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Williams arrived on Monday April 25, 2022 to conduct the annual inspection. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured he applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA and Program Manager toured facility together to ensure health and safety of clients in care. Areas toured include but are not limited to: lobby area, kitchen, activity room, large room, and bathrooms (2). In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and Program Manager completed the infection control domain together and facility was found to be in substantial compliance at this time.

LPA will email Program Manager handwashing posters to hang in the restroom.

No deficiencies are being cited as a result of todays inspection. Exit interview conducted. A copy of this report will be emaled to Program Manager
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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