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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211396
Report Date: 11/02/2022
Date Signed: 11/02/2022 06:05:25 PM


Document Has Been Signed on 11/02/2022 06:05 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:YMCA OF THE EAST BAY Y-KIDS DURHAMFACILITY NUMBER:
010211396
ADMINISTRATOR:SHAFFERS, NELDAFACILITY TYPE:
840
ADDRESS:40292 LESLIE STREETTELEPHONE:
(510) 683-9107
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:41CENSUS: 31DATE:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Payton McQuillan/Tonya RansomTIME COMPLETED:
06:15 PM
NARRATIVE
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On November 2nd, 2022 @ 2:10 pm, Licensing Program Analyst (LPA) April Wright arrived at for an unannounced Required-1 Year inspection, and met with director Payton McQuillan and Head Teacher Tonya Ransom. Present today were thirty-one (31) children and three (3) fingerprint cleared staff members present during the inspection. The facility is in ratio today. The facility was toured for a health and safety inspection. Hours of operation are Monday through Friday, 7:00am to 6:00pm.

CLASSROOMS: Center has one (1) classroom/bungalow on the Durham Elementary School campus.. There are adequate play and learning materials available. The floors, furniture, and equipment are age appropriate and in good repair. There is adequate heating/air conditioning, ventilation and lighting for safety and comfort. Drinking water is available inside and outside of the center. There is proper individual storage space for each child. The isolation area for sick children is a chair near director's desk, away from other children in care. The center has smoke/carbon monoxide detector working telephone, and one (1) fully charged 3A40BC fire extinguisher. At least one person trained in CPR/First aid is present at the facility when children are at the facility.

BATHROOMS: The staff's bathroom is separate from the classroom and are clean, sanitary and in good condition. Bathrooms for children are at Durham school located across from facility. All sinks and faucets are in safe and sanitary operating condition. .

FOOD SERVICE AREAS: This facility provides snacks only. There are weekly menus posted at the facility. All storage containers for solid waste have tight fitting covers that are in good repair.

OUTDOOR PLAY AREAS: Facility uses play yard at Durham school. There's a play structure with slide that has gravel/foam cushioning to absorb falls and that is anchored for stability. There are no pools, hot tubs or other accessible bodies of water. Per Head Teacher, there are no firearms or weapons present at facility.
See LIC809C for continuance
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: April WrightTELEPHONE: (510) 542-4257
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: YMCA OF THE EAST BAY Y-KIDS DURHAM
FACILITY NUMBER: 010211396
VISIT DATE: 11/02/2022
NARRATIVE
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RECORDS: All individuals subject to criminal record review have a clearance or exemption and have been associated to the facility. Eight (8) children's files and four (4) staff files were reviewed, along with director's file. All staff files have required health screening and Employee Rights and all children files contain Identification & Emergency, Personal Rights, and Medical Consent forms. C3 file is Incomplete - LIC627 Consent for Emergency Medical Treatment form has not been completed or signed by parent/guardian. LPA reviewed the facility roster and obtained a copy. Mandated Reporter Training and CPR and First Aid certificates were reviewed , Director and S3 have expired or no Mandated Reporter training certificates on file. The center is in compliance with the sign in and out procedure. Disaster drills are being conducted at least once every 6 months and the last one conducted was on 10/25/22. All required documents are posted in a public accessible area.

HEALTH RELATED SERVICES: NO IMS PROVIDED AT THIS FACILITY. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov . For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process .

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Violations Cited Today:

· Type A Violation: C3 file is Incomplete - LIC627 Consent for Emergency Medical Treatment form has not been completed or signed by parent/guardian.


· Technical Violation: Director Mandated Reporter certificate has expired - S3 has not completed Mandated Reporter Training.
\A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the facility representative Head Teacher Tonya Ransom.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: April WrightTELEPHONE: (510) 542-4257
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 11/02/2022 06:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: YMCA OF THE EAST BAY Y-KIDS DURHAM
FACILITY NUMBER: 010211396

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101221(b)(8)(B)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status as specified in Section 101220, and the following health information: (B) Instructions for action to be taken in case the child's authorized representative, or the
physician designated by the authorized representative, cannot be reached in an
emergency.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the director did not maintain a signed LIC 627B Consent for Medial Treatment in a child's file (C3), which poses a immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2022
Plan of Correction
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BY POC DUE DATE, 11/3/2022 by close of business day, Director agreed to obtain a completed and signed LIC627 Consent for Emergency Medical Treatment form for Child 3. A copy will be sent to Licensing Office.
Type A
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status as specified in Section 101220, and the following health information: (C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the director did not maintain a signed LIC 627B Consent for Medial Treatment in a child's file (C3), which poses a immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2022
Plan of Correction
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BY POC DUE DATE, 11/3/2022 by close of business day, Director agreed to obtain a completed and signed LIC627 Consent for Emergency Medical Treatment form for Child 3. A copy will be sent to Licensing Office.

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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: April WrightTELEPHONE: (510) 542-4257
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4