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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419963
Report Date: 03/28/2024
Date Signed: 04/04/2024 08:16:09 AM


Document Has Been Signed on 04/04/2024 08:16 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 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: 37DATE:
03/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Rachel HernandezTIME COMPLETED:
05:00 PM
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On 4/3/2024, Licensing Program Analyst (LPA) Suzette Ornelas conducted a case management visit at facility mentioned above for the purpose of investigating the incident that occurred at the facility on 03/18/2024.

The Department received the Unusual Incident Report via phone call on 03/19/2024. According to the report, on 03/18/2024, at approximately 2:50PM in the outside yard, three children exposed themselves while on the play yard. Child 2 (C2) stated that Child 1 (C1) licked their penis, and Child 3 (C3) only exposed themselves. There were two staff members present Staff 2 (S2) and Staff 3 (S3) who were supervising 17 children. The staff on site stated they did not see anything inappropriate while the kids were playing. Parent 1 (P1) of C2, emailed the school to let them know about the incident. P1 asked for the children to be monitored to make sure this does not happen again.

During todays visit, LPA Ornelas interviewed staff and children, took pictures of where the incident took place and obtained a copy of the Unusual Incident Report (UIR) (LIC628) and time stamp of when the UIR was faxed to the ESRO.

According to Staff 1 (S1) and Staff 2 (S2) children were being supervised and were meeting ratio requirements. According to C2, C2 was playing with two other children in the yard, C2 does not know what teachers were present and did not ell any of the teachers what occurred.

At this time there are no deficiencies found so no citations will be given.

Exit interview was conducted and Notice of Site Visit was provided to the Director, Rachel Hernandez.
SUPERVISOR'S NAME: Betty BellTELEPHONE: (424) 301-3063
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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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