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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197401223
Report Date: 10/28/2020
Date Signed: 10/28/2020 03:31:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
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: 27DATE:
10/28/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:VERONICA ESPINOZATIME COMPLETED:
03:30 PM
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On 10/28/2020 Licensing Program Analyst (LPA) Loyce Phillips conducted a Case Management- Incident inspection to follow up on an Unusual Incident reported to the department by telephone on 8/18/2020; this incident was reported timely. LPA spoke with Site Director, Veronica Espinoza Due to COVID-19 Emergency Response this inspection was conducted via Tele-Visit. There were 27 children in care during inspection.

Description of the incident: On 8/18/2020 at approximately 3:24 PM, child 1 was sitting in his chair and kept leaning back on the chair. Child 1 was reminding several times throughout day from several staff members to sit properly in his chair. Child 1 was leaning in his chair when the chair slipped from underneath him. Child 1 fell forward and hit the right side of his face. Child 1 was given an ice pack and parent was called right away.

Based on LPA observation, information provided and interviews conducted, the incident appears to have been an accident and no Title 22 violations have occurred; therefore, no deficiencies cited. An exit interview was conducted, and a copy of this report was read and provided to the Site Director, Veronica Espinoza.
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Loyce PhillipsTELEPHONE: (661) 305-5243
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
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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