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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455408094
Report Date: 05/19/2023
Date Signed: 05/19/2023 01:21:23 PM

Document Has Been Signed on 05/19/2023 01:21 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., SUITE 170
CHICO, CA 95926
FACILITY NAME:LACK, KIMBERLY FAMILY CHILD CARE HOMEFACILITY NUMBER:
455408094
ADMINISTRATOR:LACK, KIMBERLYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 510-1928
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
05/19/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Kimberly LackTIME COMPLETED:
01:30 PM
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Licensing Program Analyst Bianca Mendez, Licensing Program Manager Megan Aviles, and Regional Manager Jordan Monath made an unannounced site visit for the purpose of serving a Temporary Suspension Order (TSO) at 1:11PM. RM Monath explained the nature and purpose of the visit. The TSO action is being taken due to the licensee converting garage space into living space to be used for the daycare without applying for and receiving the required permit(s). The request for a fire clearance was denied.

The following documents were provided to the licensees:
1. Temporary Suspension Order (TSO)
2. Statement to Respondent
3. Government Code Sections
4. Summary Instructions for Licensee
5. Summary of Charges
6. Accusation
7. Request for Discovery
8. Notice of Defense (2)
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Bianca Mendez
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: LACK, KIMBERLY FAMILY CHILD CARE HOME
FACILITY NUMBER: 455408094
VISIT DATE: 05/19/2023
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While the order is in effect, the licensee is prohibited from operating the child day care facility. There were 10 children in care during today's visit. The written notice of the TSO was taped on the outside of the front door and must remain as long as the order is in effect. Licensee was informed that removal of this notice constitutes a violation of the law, a misdemeanor fine of up to $500.00.

The licensee shall post and provide copies of this licensing report to all parents/guardians and must give a copy of the Summary of Charges to the parent or legal guardian of each child receiving services in the facility until the Accusation is either dismissed or resolved through the administrative process or Stipulated agreement. Each parent/guardian receiving a copy of the Summary of Charges shall sign and date form LIC9224, Acknowledgement of Receipt of Licensing Reports.

Appeal Rights were provided.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Bianca Mendez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC809 (FAS) - (06/04)
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