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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016279
Report Date: 11/22/2019
Date Signed: 11/22/2019 08:27:09 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:YMCA GLB FAIRFIELD FAMILY SITEFACILITY NUMBER:
198016279
ADMINISTRATOR:ANGELICA CORTEZFACILITY TYPE:
840
ADDRESS:4949 ATLANTIC AVENUETELEPHONE:
(562) 423-0491
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY:38CENSUS: 9DATE:
11/22/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:A. VazquezTIME COMPLETED:
08:35 AM
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Licensing Program Analyst (LPA) Warren Birks conducted an unannounced Case Management-Incident inspection. This inspection is regarding an incident that took place on September 23, 2019. Licensing Program Analyst met with Teacher A. Vazquez who assisted with the inspection.

LPA interviewed staff #1. LPA to conduct follow up visit at a later date as additional staff was not available at the time.

According to the Licensing Incident report, the incident was reported to Child Care Licensing within a timely manner.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with Teacher A. Vazquez.
SUPERVISOR'S NAME: Karen ChambersTELEPHONE: (323) 980-4934
LICENSING EVALUATOR NAME: Warren BirksTELEPHONE: 323-981-3373
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2019
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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