Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313607930
Report Date: 05/03/2016
Date Signed 05/03/2016 11:52:18 AM

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:FIRST BAPTIST CHURCH A +FACILITY NUMBER:
313607930
ADMINISTRATOR:JACKSON, GAYNELLFACILITY TYPE:
840
ADDRESS:390 FAIRWAY DRIVETELEPHONE:
(530) 583-1534
CITY:TAHOE CITYSTATE: CAZIP CODE:
96145
CAPACITY:60CENSUS: 0DATE:
05/03/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gaynell JacksonTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Amie Randa met with Director Gaynell Jackson for an unannounced annual inspection. LPA toured the facility including all activity/classroom areas, food service area, restrooms and outdoor play areas. There were no school age children present today; however LPA reviewed area that the facility provides care and supervision of children, health related services, including medications, furniture, equipment and drinking water/food service provisions.

LPA reviewed the sign/in-sign/out sheet as required for school age component, and at least one staff member present today has current CPR/ First Aid that expires on 01/2018. All staff currently employed with the facility have a criminal record clearance, poisons are locked and there are no firearms or bodies of water on the property. LPA reviewed children's Identification and Emergency information and staff's educational background/transcripts.

LPA reviewed Department’s inspection authority and discussed with Director that any changes that may occur regarding the Director or an employee acting in Director's absence must be reported to department within 10 working days.

No Title 22 Deficiencies cited were observed in the areas that were evaluated. Exit interview conducted, Appeal Rights provided and Notice of Site Visit posted.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2016
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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