Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573609448
Report Date: 08/21/2017
Date Signed: 08/21/2017 12:07:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:LLOYD, TRACYFACILITY NUMBER:
573609448
ADMINISTRATOR:LLOYD, TRACYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 662-3437
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:14CENSUS: 6DATE:
08/21/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Tracy LloydTIME COMPLETED:
12:30 PM
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Licensing Program Analysts (LPAs) Seychelle De Luca and Tanya Washington met with licensee, Tracy Lloyd, for the purpose of an unannounced annual random inspection. All individuals subject to criminal background review have obtained a criminal record clearance.

A health and safety inspection was conducted in all areas accessible to children. Adequate supervision was observed. Off-limits areas include left side yard and garage. LPAs observed a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Weapons and ammunition are appropriately stored and locked. No children were observed in parked cars. There are no accessible bodies of water on the premises. Toxic and hazardous items are inaccessible to children. Safe toys and comfortable accommodations were observed. The fireplace in the home was appropriately barricaded to prevent access by children. Outdoor play space is fenced.

Children's records were reviewed. Emergency information and required immunization records were on file. Preventative health training, current pediatric CPR and first aid certification was verified and expires 4/29/2019.

Report continues on 809-C.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De LucaTELEPHONE: 916-217-4316
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2017
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: LLOYD, TRACY
FACILITY NUMBER: 573609448
VISIT DATE: 08/21/2017
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

This facility evaluation report was reviewed and discussed with the licensee. A notice of site visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Seychelle De LucaTELEPHONE: 916-217-4316
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2017
LIC809 (FAS) - (06/04)
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