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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 213000337
Report Date: 12/11/2019
Date Signed: 12/11/2019 03:59:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MARIN YMCA @ MANOR (SA)FACILITY NUMBER:
213000337
ADMINISTRATOR:MARIE-CLAIRE CHOUDHURYFACILITY TYPE:
840
ADDRESS:150 OAK MANOR DRIVETELEPHONE:
(415) 456-5349
CITY:FAIRFAXSTATE: CAZIP CODE:
94930
CAPACITY:70CENSUS: 39DATE:
12/11/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Jordan JamesTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Farhan Bashir-Tariq conducted a case management inspection today in response to an unusual incident report that Department received on November 12, 2019. Facility self-reported the incident. Present there were 39 children in care with 4 staff. This incident occurred when C1 suddenly fell on the floor while eating carrots.

Staff responded to the occurrence immediately and approached and tapped C1 thinking, it could be a food allergy reaction but C1 was unresponsive. Paramedics were called and parents/Guardians of C1 were also informed about the incident right away. Paramedics and Dad arrived at the same time. Paramedics after the initial investigation decided to take C1 to hospital.

During today's inspection, LPA spoke to Program Director, Jordan James. Per Jordan, C1 did not miss any days from the program and was back in the school at her regular days. Per Jordan, C1 was diagnosed of epilepsy and had a seizure at the time of incident. C1 was diagnosed first time of epilepsy. Per Jordan, there was no know history to the parents. No information was provided to the facility regarding the matter. C1 was advised by Doctor to not climb on the playground structures and if the episode of seizure last more than 3 minutes to call paramedics. Parents shall be informed of each occurrence at the facility regardless of the time restrictions.


>NO deficiencies were cited today under Title 22 Division 12 of the California Code of Regulations. This report and rights to comment and appeal were discussed with Jordan. This report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit. Licensee was advised for any additional questions to call Office, M-F, 8AM-5PM at 650-266-8800. For Rules and Regulations, visit the Website: www.cdss.ca.gov

SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Farhan Bashir-TariqTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2019
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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