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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494850
Report Date: 06/08/2021
Date Signed: 07/08/2021 10:14:45 AM

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:BURBANK YMCA HORACE MANN CHILDRENS CENTERFACILITY NUMBER:
197494850
ADMINISTRATOR:ANGELA BUCKFACILITY TYPE:
830
ADDRESS:3401 SCOTT ROADTELEPHONE:
(818) 729-1650
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:45CENSUS: 8DATE:
06/08/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Angela Buck/Assistant Director and Rebecca Kelly/DirectorTIME COMPLETED:
10:30 AM
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 6/08/2021 at 8:00 AM, Licensing Program Analyst (LPA), Silva Garibyan made an announced visit to Burbank Community YMCA Horace Mann Children's Center for the purpose of conducting a change of ownership pre-licensing visit. LPA Garibyan met with Sr. Director/Assistant Director for Infants, Angela Buck and Director, Rebecca Kelly. LPA Garibyan toured the facility. The applicant is requesting an infant license with a toddler option for a capacity of 45 children. Requested hours of operation are Monday - Friday 7:00 AM - 6:00 PM. At the time of the visit there were 8 children present with the director and five teachers.
An approved fire clearance was conducted by Fire Inspector Laurie Brightwell from the Burbank Fire Prevention Bureau on 5/25/2021.
There is one classroom assigned for the infant program. Toddler option is also requested with the infant license. There are two classrooms assigned for the toddler option.

Infant Indoor Measurements ( not including the separated crib area)
Infant classrooms: 26 x 31 = 806 sq. ft/35 = 23 infants

Infant Outdoor Measurement: (21.4 x 29.4) - ( 4 x 7.9) + ( 38.9 x 61) = 629.16 - 31.6 + 2,372.9 = 2,970.46/75 = 39 infants

Toddler indoor Measurements
Classroom # 1: 29 x 29 = 841 sq. ft/35 = 24 toddlers
Classroom # 2 : 29 x 29 = 841 sq. ft/35 = 24 toddlers
Toddler Outdoor Measurements:
Toddler yard: 72 x 24 = 1,728 sq. ft/75 = 23 toddlers
Multi use outdoor space: 37 x 50 = 1,850 sq. ft/75=24 toddlers Page 1 of 6



SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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 6
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: BURBANK YMCA HORACE MANN CHILDRENS CENTER
FACILITY NUMBER: 197494850
VISIT DATE: 06/08/2021
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
The infant and toddler yards are enclosed by fences to restrict the areas to Infant and toddler use only. The yards contain infant and toddler age appropriate play equipment.
The crib area contains 7 cribs. The classroom contains a changing table within arms reach of a sink. There is a refrigerator for Infant milk and meal storage. Crib bedding will be washed by the center daily. Labels will identify each child's crib. There is one children and one staff bathroom in the infant room.
Parents will provide lunch, snack, baby food or milk for infants and toddlers enrolled in this program. Medications will be stored in a medication box in the nurse's office. First aid supplies are available in infant and toddler classrooms. Sign in/out procedures will be implemented at the entrance of the classrooms. The classroom will have a list of infants and toddlers signed in for the day. There is water readily available in infant and toddler classrooms.
Director understands that Infant and toddler Teachers must have Infant/toddler units. Minimum staffing ratios are 1 teacher to every 4 infants. 1 teacher and 1 aide may supervise up to 8 infants and 1 teacher to every 6 toddlers. Applicant is also aware of Infants Needs and Services Plans and the requirement to conduct meetings as needed with infant families to update the Needs and Services Plans. Logs will be kept in the classroom for staff to document Infant feedings and diaper changes.

Facility is equipped with a sprinkler system and fire alarm system. Fire Extinguishers and Carbon monoxide detectors were observed in all classrooms. Facility has central heating and air. Trash cans were observed with appropriate lids. First aid kits were observed to have: bandages, adhesive tape, scissors, tweezers, and antiseptic solution.

Directors office will be used for isolation of ill children. Required postings were observed outside of each classroom for public viewing. Parent / guardian sign in and out will be in each classroom. Facility has a working phone land line available ( 818-729-1650). All medications will be stored in the nurse's office.

Page 2 of 6

SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: BURBANK YMCA HORACE MANN CHILDRENS CENTER
FACILITY NUMBER: 197494850
VISIT DATE: 06/08/2021
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
Food Service:
There is a clean, fully equipped kitchen. Parents will provide lunch and snacks. Food is available in the event a child's lunch and snacks are forgotten. The chemicals are kept separate from the food.

The following was discussed with the applicant:

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.html.

Required Postings/Licensee shall have posted in the Child Care Center at all times the following:


Facility license.
Personal Rights form (LIC 613A).
Menus.
Child passenger restraint system poster. (PUB 269).
Daily activity schedule.
Emergency Disaster Plan (LIC 610) and Earthquake Preparedness Checklist (LIC 9148) Parent’s Rights Poster (PUB 393).
Notice of Site Visit (LIC 9213).
Any licensing report documenting a type”A” citation must be posted for 30 days.
Any licensing report or other document verifying compliance or non-compliance with the Department’s order to correct a Type A deficiency must be posted for 30 days.

Employee/Volunteer Files shall also be maintained and shall contain the following


Health Screening Report - Facility Personnel (LIC 503) and TB Clearance.
Proof of Immunization's
Page 3 of 6
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: BURBANK YMCA HORACE MANN CHILDRENS CENTER
FACILITY NUMBER: 197494850
VISIT DATE: 06/08/2021
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
TB Clearance and "Good Health" statement from volunteers.
Personnel Record (LIC 501) or application/resume.
Evaluation of Director Qualifications (LIC 9096).
Evaluation of Teacher Qualifications (LIC 9095).
For each aide under age 18, verification of high school graduation or current participation in an occupational program conducted by an accredited high school or college.
Criminal Record Statement (LIC 508) for staff subject to fingerprint requirements.
Fingerprint clearances - Proof of clearance (Criminal Record, FBI and Child Abuse).
Appropriate driver's license for person(s) transporting children.

Mandated Reporter: Beginning on January 1, 2018, AB 1207, requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training.
Website: www.mandatedreporterca.com

Senate Bill (SB) 792: This bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles.

Senate Bill (SB) 277 New Immunization Requirement: Beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into child care or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.

SIDS & SHAKEN BABY SYNDROME INFORMATION: LPA discussed safe sleep for infants with applicant: Infants must be placed on their backs and must be physically checked every 15 minutes to gauge temperature and ensure they are breathing. Applicant reviewed both items provided and understands the guidance of safe sleep practices. .



Page 4 of 6
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: BURBANK YMCA HORACE MANN CHILDRENS CENTER
FACILITY NUMBER: 197494850
VISIT DATE: 06/08/2021
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
Safe Sleep Links:
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

Licensee shall maintain Administrative Records which shall have the following:


Administrative Records
Written inspection procedures for accepting children on a daily basis.
Sign-in/sign-out sheets kept for current 30 days, or approved waiver to use electronic pin system.
Admission policies, including admission criteria, ages of children who will be accepted; medical assessment requirements; program activities, supplemental services, if any; field trip provisions, transportation arrangements, food service, if any.
Designation of Facility Responsibility (LIC 308).
Personnel Report (LIC 500) showing current roster.
Licensee affidavit regarding persons exempt from fingerprint requirements (Use back of LIC 500).
Emergency Disaster Plan (LIC 610) (a posting requirement; see below) with verification that disaster drills are conducted every six months. Documentation of drills shall be maintained for at least one year.Up-to-date list of qualified teacher substitutes.
Documentation of exceptions and waivers: Facility Waiver Request (LIC 956) and Exception/Exemption Request (LIC 971).
Annual licensing reports and substantiated complaints from the last three years (must be available at the center for public review). and a Child Care Facility Roster (LIC 9040).

The applicant was informed of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on child care licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541.
Email Address: childcareadvocatesprogram@dss.ca.gov
Page 5 of 6
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: BURBANK YMCA HORACE MANN CHILDRENS CENTER
FACILITY NUMBER: 197494850
VISIT DATE: 06/08/2021
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
Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment. All appeals must be sent to:

California Department of Social Services | Community Care Licensing Division

300 N. Continental Blvd. Suite, 290-A

El Segundo, CA 90245

The following items are pending prior to licensure to be completed by:

Final File Review

A copy of this report will be electronically mailed to the applicant for review and signature

A read receipt shall confirm as receipt of the electronically delivered report.

Applicant shall print and sign the report and mail the report to the licensing office, with an original signature.

If there are any questions or concerns, please contact the department at (424) 301-3077

SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Silva GaribyanTELEPHONE: (424) 301-3062
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6