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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393612245
Report Date: 11/18/2022
Date Signed: 11/18/2022 11:46:41 AM

Document Has Been Signed on 11/18/2022 11:46 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:LOVINS, KIMBERLYFACILITY NUMBER:
393612245
ADMINISTRATOR:KIMBERLY LOVINSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 838-8963
CITY:ESCALONSTATE: CAZIP CODE:
95320
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
11/18/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:licensee, Kimberly LovinsTIME COMPLETED:
12:00 PM
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On November 18, 2022, Licensing Program Analyst (LPAs) Lauren Scott and Tobias Lake met with Licensee, Kimberly Lovins for the purpose of a case management inspection due to deficiencies.

LPA Lauren Scott received a complaint on October 13, 2022 regarding an incident that occurred with a child wandering away from the facility. Upon investigation, LPA Scott did not receive an Unusual Incident Report regarding the incident. All unusual incidents, including a child wandering from facility, need to be reported to CCLD within 24 hours and a LIC 624B needs to be submitted within 7 days of the occurrence.

LPA Scott informed licensee that this report dated November 18, 2022, documents one Type B citation, stating there is a potential risk to the health, safety, or personal rights of children in care.

Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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Document Has Been Signed on 11/18/2022 11:46 AM - It Cannot Be Edited


Created By: Lauren Scott On 11/18/2022 at 11:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: LOVINS, KIMBERLY
FACILITY NUMBER: 393612245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
102416.2(b)(2)

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102416.2 Reporting Requirements. (b) The licensee shall report to the Department any of the events... Any child absence means any instance where a child in care is missing... shall be reported even if the child is later found safe. This requirement was not met by evidenced by:
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LPA provided copies of LIC624B for licensee to use. Licensee stated she will call the officer of the day with any questions regarding if an incident needs to be reported or not
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Licensee did not inform CCLD of the unusual incident that occurrent, within 24 hours, nor did she submit a LIC624B within 7 days. This is a potential health and sfety risk to children 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:Chayntel Hunter
LICENSING EVALUATOR NAME:Lauren Scott
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
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