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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419963
Report Date: 05/02/2022
Date Signed: 05/02/2022 12:40:47 PM


Document Has Been Signed on 05/02/2022 12:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:YMCA OF METRO LA/WEST VALLEY CALABASHFACILITY NUMBER:
197419963
ADMINISTRATOR:RACHEL HERNANDEZFACILITY TYPE:
840
ADDRESS:23055 EUGENE STREETTELEPHONE:
(424) 536-0189
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:75CENSUS: 0DATE:
05/02/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Rachel HernandezTIME COMPLETED:
12:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 05/02/22, Licensing Program Analyst Laticia Thompson conducted an unannounced Case Management – COVID-19 inspection to follow up on reported positive cases of COVID-19. Upon arrival, LPA met with Rachel Hernandez (Director) . LPA conducted a risk assessment and toured the facility. LPA observed 0 children and 0 staff.

According to the Unusual Incident Reports LIC 624, on 01/13/22, 01/14/22, 01/15/22 4 children and 0 staff tested positive for COVID-19.

Licensee stated that all children who tested positive for COVID-19 isolated and were cleared to return to the facility on.



During the visit, LPA observed COVID-19 related signs/posters throughout the facility. Each classroom includes a sanitation area. LPA observed all bathrooms fully stocked with soap and paper towels. Materials and equipment are not shared only tables
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:
DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: YMCA OF METRO LA/WEST VALLEY CALABASH
FACILITY NUMBER: 197419963
VISIT DATE: 05/02/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the visit LPA and Licensee discussed the following best practices:

Face Masks – The department high recommend that all children and staff are wear face mask indoors. Face masks are no longer required outdoors.

Isolation area - Isolation area is located in a tent ouside. A designated staff will stay with the child until the parent arrives. The facility has an isolation restroom for children with symptoms.



Cleaning and Disinfecting - The outdoor play area and classrooms are sanitized daily. High-touch surface areas are sanitized throughout the day.

Reporting Requirements – LPA explained and reminded Licensee to report all COVID-19 positives cases to Department of Public Health. In addition, report all positives cases and closure of facility or classrooms to Community Care Licensing. When reporting Unusual Incidents, call CCLD within 24 hours and submit Unusual Incident Report within 7 days.

No deficiencies are cited, per Title 22, Division 12, Chapter 3, of the California Code of Regulations.

An exit interview was conducted and a copy of this report (LIC 809) and Notice of Site Visit were provided to Licensee.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Laticia S ThompsonTELEPHONE: (424) 301-3048
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2