013419475-10-23-2019-02-CC-DPEZ-BHJ2AE-20191101171324

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 013419475
Report Date: 10/23/2019
Date Signed: 10/23/2019 03:19:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/22/2019 and conducted by Evaluator Dayna Collier

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20191022122356

FACILITY NAME:	YMCA OF THE EAST BAY - 21ST STREET CDC		FACILITY NUMBER:	013419475
ADMINISTRATOR:	HAYES, KISHA		FACILITY TYPE:	850
ADDRESS:	756 - 21ST STREET		TELEPHONE:	(510) 272-0669
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94612
CAPACITY:	103	CENSUS: 0	DATE:	10/23/2019
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Shawn Bryant		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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LACK OF SUPERVISION: Lack of supervision resulting in a child wandering away from the childcare.

INVESTIGATION FINDINGS:

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LPA Dayna Collier met with Acting Center Director Shawn Bryant for a complaint investigation regarding the above allegation. Also present for the investigation were Allona Gill, Asst. Center Director and Shannon Edwards, Health and Nutrition Manager. It was alleged that an incident occurred when a child wandered away from the facility. During the course of the investigation, interviews were conducted. Prior to today's investigation, the facility submitted an unusual incident report to Licensing. Per staff, the child wandered away from the playground, walked through the facility and exited through the front door. The staff member on the playground transitioned the children into the classroom where another staff member noticed that the child was missing. Staff began to search all the classrooms and the surrounding area. The child was located around the corner sitting on the street. Per staff, the child was unsupervised for about 9 minutes. Following the incident, the staff members involved were terminated. Based on the LPA's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Ch. #1011219), are being cited on the attached LIC 9099D. SEE 9099C ATTACHED.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Diane Perez	TELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Dayna Collier	TELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 02-CC-20191022122356

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: YMCA OF THE EAST BAY - 21ST STREET CDC	FACILITY NUMBER: 013419475
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/23/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/24/2019 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time	1 2 3 4 5 6 7	POC: Prior to today's investigation, a mandatory training was conducted with all staff. Written summaries were submitted to Licensing. In addition, the staff members involved were terminated. THIS IS A ZERO TOLERANCE VIOLATION WHICH RESULTS IN A $500 CIVIL PENALTY.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by report review and interviews which poses an immediate risk to children in care. A CHILD WANDERED AWAY FROM THE FACILITY WITHOUT STAFF'S KNOWLEDGE AND/OR OBSERVATION. AN LIC 421IM FORM WAS GIVEN.	8 9 10 11 12 13 14	SUBSEQUENT VIOLATIONS MAY RESULT IN $1000 IMMEDIATE CIVIL PENALTY.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Diane Perez	TELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Dayna Collier	TELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

LIC9099 (FAS) - (06/04)

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Control Number 02-CC-20191022122356

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: YMCA OF THE EAST BAY - 21ST STREET CDC	FACILITY NUMBER: 013419475
	VISIT DATE: 10/23/2019

NARRATIVE

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Upon receipt, licensee shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

An exit interview was conducted and the report was discussed. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and the signature on this form acknowledges receipt of these rights.

A SITE VISIT NOTICE WAS POSTED BY THE DIRECTOR.

SUPERVISOR'S NAME: Diane Perez	TELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Dayna Collier	TELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2019

LIC9099 (FAS) - (06/04)

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