<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073406655
Report Date: 12/03/2019
Date Signed: 12/03/2019 03:00:51 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
11/06/2019 and conducted by Evaluator Brittany Newton
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20191106165420
FACILITY NAME:YMCA OF THE EAST BAY - MOUNTAIN VIEWFACILITY NUMBER:
073406655
ADMINISTRATOR:KHALAFALLAH, EMANFACILITY TYPE:
840
ADDRESS:1705 THORNWOOD DRTELEPHONE:
(925) 689-1170
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:50CENSUS: 38DATE:
12/03/2019
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Director Crystal ImpeartriceTIME COMPLETED:
03:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
PERSONAL RIGHTS: Child exposed themself to another child while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/3/2019, Licensing Program Analyst (LPA) Brittany Newton and Licensing Program Manager (LPM) Sherelle Johnson met with Director Crystal Impeartrice for a complaint investigation regarding the above allegation. Present for the investigation were the Director, four staff members and 38 children in care. Today, LPA interviewed two children and two staff. During the course of the investigation, interviews were conducted and documentation was reviewed. It was alleged that a child exposed themself to another child in care. The facility's supervision while outside was discussed. Interviews conducted revealed that a child did expose themself to multiple children on at least one occasion. Based on interviews conducted and information gathered, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12, Chapter 1, 101223), is being cited. The attached type B deficiency is cited today and must be corrected by the due date. An exit interview was conducted and the report was discussed. Licensee was provided a copy of their appeal rights and the signature on this form acknowledges receipt of reports. A notice of site visit was provided at the time of the visit.
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Brittany NewtonTELEPHONE: (510) 622-2594
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 02-CC-20191106165420
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 - MOUNTAIN VIEW
FACILITY NUMBER: 073406655
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2019
Section Cited
CCR
101223(a)(3)
1
2
3
4
5
6
7
101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Facility agrees to submit a plan regarding supervision while indoors and outdoors by 12/27/2019 to LPA Newton.
8
9
10
11
12
13
14
Based on interviews conducted and documentation obtained, a child exposed themself to multiple children which poses a potential Health, Safety, or Personal Rights risk to children in care.
8
9
10
11
12
13
14
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: Sherelle JohnsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Brittany NewtonTELEPHONE: (510) 622-2594
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019
LIC9099 (FAS) - (06/04)
Page: 2 of 2