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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017013
Report Date: 04/07/2022
Date Signed: 04/07/2022 01:49:07 PM

Document Has Been Signed on 04/07/2022 01:49 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:YMCA GLB LOS CERRITOSFACILITY NUMBER:
198017013
ADMINISTRATOR:MICHELE JANSSENFACILITY TYPE:
840
ADDRESS:15530 WOODRUFF AVENUETELEPHONE:
(562) 925-1292
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 80TOTAL ENROLLED CHILDREN: 80CENSUS: 0DATE:
04/07/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Michele Jassen, Administrator & Debbie Duran Gomez, DirectorTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Susann Sanchez conducted an announced case management- licensee initiated to review paperwork. Upon arrival, LPA met with Michele Jassen, Administrator & Debbie Duran Gomez, Director who provided LPA a tour of the facility inside and outside.

LPA reviewed all director qualifications for Debbie Duran Gomez and copies were collected for the file:
  • LIC 308- Designation of Responsibility
  • Orientation Certificate and dated 02/16/2015
  • LIC 501- Personnel Record - Degree in Child Development and 12 years of experience
  • Current CPR and 1st Aid: expires on 06/10/2022
  • Health Screening
  • Immunizations
  • Mandated Reporter: expires 02/19/2023
  • LIC 508- Criminal Record Statement
  • LIC 9108- Statement Acknowledgement
  • Health and Safety Training with 1 hour of nutrition and lead poisoning

LPA also reviewed Dalia Trujillio file for teaching qualifications for School - Age. The following was reviewed: As stated in regulation: 101516.2 (b)

As an alternative educational prerequisite, a school-age child care teacher may, pursuant to Health and Safety Code Section 1597.21, substitute 20 training hours for each of the required units of education in Section 101216.1. Units and training hours may be combined to meet the total educational requirement (12 units or 240 training hours, or any combination thereof)

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LOS CERRITOS
FACILITY NUMBER: 198017013
VISIT DATE: 04/07/2022
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As of 09/28/2020, Dalia Trujillio has 276 hours of training. This is not including the training that was taken in 2021 and 2022. File also included current licensing documents, therefore Dalia Truilllio meets the requirements to be a teacher.

Per California Code of Regulations Title 22, Division 12, no deficiency cited during today's visit. Exit interview conducted with the Michele Jassen, Administrator.

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.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
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