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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010200607
Report Date: 05/09/2022
Date Signed: 05/26/2022 12:53:23 PM


Document Has Been Signed on 05/26/2022 12:53 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/25/2022 07:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

NARRATIVE
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This is an amended version of an original report dated on May 6, 2022.

On May 6, 2022 Licensing Program Analysts (LPAs), Melissa Domantay and Indira Loza, conducted an unannounced case management inspection due an Unusual Incident Report received on April 1st, 2022. LPAs met with Director Dorian Burnley, and toured the full facility that is utilized by the Preschool component. LPAs observed 7 staff and 24 children in care. LPAs inspected the Preschool to ensure the Health and Safety of children in care.

During today's inspection LPAs conducted staff interviews. See 809-D for Type A deficiency.

Exit interview conducted. A copy of report and appeal rights provided to Director Dorian Burnley.

Deficiency was cited for a teacher violating a child's personal rights when she pinched them. Although it may or may not have been an accident, the child's personal rights were violated. See 809-D for the deficiency 101223(a)(3) and personal rights.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 05/31/2022 11:18 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/25/2022 07:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: BERKELEY YMCA HEAD START - SOUTH YMCA
FACILITY NUMBER: 010200607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/12/2022
Section Cited

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To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation...and mental abuse This requirement was not met as evidenced by staff interviews. This poses an immediate health and safety risk to children in care. It was determined that the teacher pinched the child who was flailing his arms and was attempting
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to keep the child from hitting the same teacher, and snapping thier fingers in the child's face.
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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: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022
LIC809 (FAS) - (06/04)
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