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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197401223
Report Date: 08/13/2019
Date Signed: 08/13/2019 02:37:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:YMCA OF METRO L.A./HARDING SITEFACILITY NUMBER:
197401223
ADMINISTRATOR:VERONICA ESPINOZAFACILITY TYPE:
840
ADDRESS:13060 HARDING STREET, #28TELEPHONE:
(818) 838-4653
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY:70CENSUS: 45DATE:
08/13/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Veronica EspinozaTIME COMPLETED:
02:38 PM
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Licensing Program Analyst's (LPAs) Smith and Thompson-Miller met with Veronica Espinoza, Director, for a Case Management Incident inspection involving an Incident Report dated July 22, 2019. The incident occurred on July 17, 2019.

Description of the incident: Child #1 tripped while playing football, fell hurting his right elbow.
The focus of the inspection is to interview children and staff. Director informed LPA Child #1 no longer attends the after school program, (only attended for summer camp). Interviews were conducted with children and it was determined that child #1 attempted to catch the football, missed it and tripped over his own footing. He was not pushed, shoved or interfered with in any way to cause his injury. Per parent, child was taken to the doctor, last day in attendance was August 1, 2019.

Staff #1 - Not present during inspection however she was a witness to the incident.

Based on information provided and interviews conducted, the incident does not appear to have been the result of any violation of the Title 22 regulation, therefore, no deficiencies were cited. An exit interview was conducted and a copy of this report was read and provided to the Director, Veronica Espinoza on this date.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Suzanne SmithTELEPHONE: (661) 305-3012
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
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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