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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213008
Report Date: 07/10/2019
Date Signed: 07/10/2019 10:46:56 AM

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 MARSHALLFACILITY NUMBER:
010213008
ADMINISTRATOR:CINDY AGERSFACILITY TYPE:
840
ADDRESS:20111 MARSHALL ST.TELEPHONE:
(510) 581-4996
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:60CENSUS: 33DATE:
07/10/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Cindy AlvarezTIME COMPLETED:
11:00 AM
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On 07/10/19, Licensing Program Analyst (LPA) Briana Plumboy conducted an unannounced Case management inspection at this facility as a response to an unusual incident received which was reported by the Center Director. LPA Plumboy met with Director Cindy Alvarez. There were 4 staff and 33 children present. LPA Plumboy and Director Cindy Alvarez toured the center and playground.

On 06/26/19, it was reported a child tripped over a stationary rock on the playground causing him to hurt his right knee. The child received medical attention. 2 staff witnessed the incident occur.

As a result of this visit, there are no deficiencies cited during today's visit. This report must be available for public review for 3 years. An exit interview was conducted and a site visit notice was posted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2019
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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