300606914-8-9-2019-06-CC-SHAS-BEVSBD-20190809134345

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300606914
Report Date: 08/09/2019
Date Signed: 08/09/2019 01:44:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	CENTRAL ORANGE COAST YMCA - BENSON SCHOOL		FACILITY NUMBER:	300606914
ADMINISTRATOR:	CALERO, MARGARITA		FACILITY TYPE:	840
ADDRESS:	12712 ELIZABETH WAY		TELEPHONE:	(714) 544-0173
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	116	CENSUS: 33	DATE:	08/09/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Te'Vari Jenkins		TIME COMPLETED:	02:15 PM

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	Licensing Program Analyst (LPA) Hawkins met with the site director Te'Vari Jenkins, for a random annual inspection. LPA toured the facility, including all activity/classroom areas, the isolation area, rest-rooms and outdoor play areas. This facility is located in the portable building #Y1 located on Benson Elementary School site. LPA observed 33 school-age children with 6 staff including the site supervisor. A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reviewed care and supervision of children, staffing ratios, health related services, including medications and first aid supplies, furniture, equipment, fire drills, drinking water and food service provisions. LPA observed all required forms to be posted. Medications are stored in a cabinet inaccessible to children in care. Some first aid materials were available. There are adequate toys and equipment available for children. The facility uses the elementary restrooms during after school hours when the regular elementary school children are no longer on campus.The restroom was observed to be in working order. The facility provides AM/PM snacks and lunch which are delivered to the site daily. The program operates from 7:00 a.m.- 6:00 p.m. The facility has an electronic parent sign in/out procedure. LPA reviewed the printed children's roster and personnel records. At least one staff member present today have current Pediatric CPR and First Aid ( exp 5/11/21) throughout the day. The facility has fire extinguisher, smoke and carbon monoxide detectors which was found to be in working order. LPA reviewed staff and children's files as well as LIC500 and children's roster. Children files were reviewed for emergency identification forms and all files were complete. Staff files were reviewed for educational requirements, CPR/First Aid and health screenings, and were found to be complete. Incidental Medical Services (IMS) policy was discussed. Director reported that the facility does provide IMS services however there is no one enrolled who requires IMS services at this time. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. Continued on page 2

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CENTRAL ORANGE COAST YMCA - BENSON SCHOOL	FACILITY NUMBER: 300606914
	VISIT DATE: 08/09/2019

NARRATIVE

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When any IMS is provided, a Plan for Providing 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.htm .

The director was advised on how to receive notifications about quarterly updates, and provided with the Child Care Advocate contact information:mailto:mailto:childcareadvocatesprogram@dss.ca.gov childcareadvocatesprogram@dss.ca.gov

Beginning January 1, 2018, Health and Safety Code 1596.8662 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, per A.B. 1207.

There were no Title 22 deficiencies cited during today's inspection.

Exit interview was conducted, and report was reviewed and discussed. Notice of Site Visit was posted during the visit. The director was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100 per day. The director was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional manager, address is above on the report. The director was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov. This report is to be on file and accessible for public review at the facility for at least 3 years.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene Hawkins	TELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019

LIC809 (FAS) - (06/04)

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