300607121-9-6-2019-06-CC-GCOY-BFS2WM-20190906174545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300607121
Report Date: 09/06/2019
Date Signed: 09/06/2019 05:46:02 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:	CAPISTRANO BEACH CITIES YMCA- DEL OBISPO		FACILITY NUMBER:	300607121
ADMINISTRATOR:	BOYER, RICK		FACILITY TYPE:	840
ADDRESS:	25591 CAMINO DEL AVION		TELEPHONE:	(949) 493-4315
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY:	90	CENSUS: 42	DATE:	09/06/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Director: Rick Boyer		TIME COMPLETED:	06:00 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	LPA Connolly conducted a case management inspection today to review a self reported incident that had been received in the licensing office on 7/11/19. According to the self reported incident: on 7/10/19 while the Del Obispo YMCA was on an outing to an amusement park, a child in care, was discovered missing during a head count. A search of the area was initiated. According to the self reported incident the child was estimated to be missing no more than three minutes and was located by another YMCA director. At the time of the LPA arrival census was taken. There were a total of 42 children in care with 4 attending staff. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances. During today's case management inspection the director was interviewed regarding the 7/10/19 incident. The director provided a copy of Field Trip Procedures and a copy of the meeting minutes of a staff meeting held 7/11/19 which addressed field trip procedures. The signatures of the attending staff was included. The director was informed that the following violation of the California Code of Regulations, Title 22; Division 12, Section 101223(a)(1) is cited on the accompanying 809 D. An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the licensing office within 15 business days. If the facility receives a Type 'A' violation the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility by the next business day and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. The facility representative was informed that the 'Notice of Site Visit' must be posted for 30 consecutive days. Failure to post will result in civil penalty of $100.00. The 'Notice of Site Visit' ' must be posted on or adjacent to the door. Failure to post Type A reports for 30 days will result in a civil penalty of $100.00.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine Connolly	TELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2019

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: CAPISTRANO BEACH CITIES YMCA- DEL OBISPO	FACILITY NUMBER: 300607121
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/06/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/06/2019 Section Cited	1 2 3 4 5 6 7	Care and Supervision. No child shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). According to a self reported incident by the facility, a child in care was missing during a Del Obispo YMCA outing to an amusement park. A search was initiated.
	8 9 10 11 12 13 14	and the child was located by another YMCA director. Child was returned to the Del Obispo YMCA group. It is estimated child was missing no more than three minutes. The care and supervision regulation was not met as evidenced by director interview and report sent to our office.	8 9 10 11 12 13 14	An absence of supervision is an immediate risk to the health and safety of children in care. An immediate civil penalty of $500.00 is hereby assessed for absence of supervision
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine Connolly	TELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2019

LIC809 (FAS) - (06/04)

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