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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197403360
Report Date: 07/21/2021
Date Signed: 07/21/2021 09:57:19 AM

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 METRO LA/ANTELOPE VALLEY QUARTZ HILLFACILITY NUMBER:
197403360
ADMINISTRATOR:CANDACE BEDNARFACILITY TYPE:
840
ADDRESS:41820 50TH STREET WESTTELEPHONE:
(661) 943-3303
CITY:QUARTZ HILLSTATE: CAZIP CODE:
93536
CAPACITY:105CENSUS: 19DATE:
07/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Jessica HernandezTIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Aaron Mabika conducted an unannounced case management inspection to the above facility for the purpose of gathering information for an incident involving a child reported to the RO on 07-20-2021. A tour of the facility was undertaken and the census was recorded at 19 children in care with 3 staff. LPA received a current facility roster, a DCFS number and other relevant paperwork. LPA also collected the new site supervisor's file for a review of the director qualifications.

Exit interview conducted with Jessica Hernandez and a copy of report given
SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Aaron MabikaTELEPHONE: (661) 305-7599
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021
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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