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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005499
Report Date: 09/20/2021
Date Signed: 09/20/2021 01:01:15 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 AFP AT WADE THOMAS ELEMENTARY SCHOOLFACILITY NUMBER:
214005499
ADMINISTRATOR:KELLEY, TORREYFACILITY TYPE:
840
ADDRESS:150 ROSS AVENUETELEPHONE:
(415) 452-7582
CITY:SAN ANSELMOSTATE: CAZIP CODE:
94960
CAPACITY:100CENSUS: 0DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Area Coordinator, Jeani CalaguiTIME COMPLETED:
01:10 PM
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On September 20th, 2021, at 11:30 am, An annual comprehensive inspection was conducted today. Facility is located on functioning public school site. Licensing Program Analyst (LPA), Kassandra Medrano inspected the facility building and grounds, conducted an evaluation of the physical plant, and reviewed children, staff and facility records. A review of staff records during today’s visit indicates that all staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The program operates Monday- Friday 12pm- 6pm. The following was observed today: During review of files, at 12:15pm 5 TK students arrived. Current site supervisor is Jeanie Calagui. Current room used for care is room 8. The following items were reviewed as part of today's visit: Care and Supervision of the Children, Child Discipline Procedures, Emergency Evacuation Procedures (smoke and carbon monoxide detectors present and in working order), Medication Policies, Isolation of Sick Children, room 16 is used for isolation, Food Service, Transportation, Parents Rights, and Reporting Requirements. Bathrooms for school age children are located down the all from the classroom. Supervision of school age children coming and going from the bathrooms and at the bathrooms is achieved by 3 plus me, meaning staff plus three students will go to restroom together. The outdoor play area is located outside of classroom, facility has access to entire blacktop and play structure across from classroom. Supervision of school age children using a functioning school site public playground is achieved by two staff outside with children. Children are signed in to the facility by staff and out of the facility by parents/guardians.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 AFP AT WADE THOMAS ELEMENTARY SCHOOL
FACILITY NUMBER: 214005499
VISIT DATE: 09/20/2021
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 Posting requirements for site visits were discussed. Current forms and Title 22 Regulations can be obtained through the internet at www.ccld.ca.gov. Staff immunization are on file. Director was reminded that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. Influenza Declarations were also reviewed. Director was advised of the required annual pesticides training. For More information about changes to the Healthy Schools Act, templates, or articles, you can inspect the DPR website at: https://apps.cdpr.ca.gov/schoolipm/childcare/training/main.cfm . Director was informed about the Provider Information Notices (PINs) on CCLD website. This facility provides IMS. A review of storage of medications, equipment and supplies, and reviewed children, personnel and administrative records.

"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS.

SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Kassandra MedranoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC809 (FAS) - (06/04)
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