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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010210508
Report Date: 09/19/2023
Date Signed: 09/19/2023 01:16:33 PM


Document Has Been Signed on 09/19/2023 01:16 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:YMCA OF THE EAST BAY Y-KIDS CHADBOURNEFACILITY NUMBER:
010210508
ADMINISTRATOR:KWAN, JOSEPHFACILITY TYPE:
840
ADDRESS:801 PLYMOUTH AVENUETELEPHONE:
(510) 656-7243
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:60CENSUS: 9DATE:
09/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Hailey RoweTIME COMPLETED:
01:20 PM
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On 9/19/2023, Licensing Program Analyst (LPA) Melanie Otsuji conducted an unannounced Case Management - Other inspection. A visit was conducted due to facility requesting to go from Inactive License Status to Active License status. LPA met with Head Teacher, Hailey Rowe. Also present during today's visit were 2 additional staff members and 9 school aged children. LPA conducted a health & safety inspection of the facility.

Facility uses a portable classroom located on the campus of Chadbourne Elementary School. Facility staff stated that facility utilizes the elementary school bathrooms and playground. Staff understand that children are not allowed to commingle with the elementary children. LPA did a quick review of staff and children's files.

This Facility is now on active status as of today 9/19/23. No deficiency was cited in today’s visit.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Head Teacher, Hailey Rowe.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023
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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