300611755-12-5-2019-06-CC-RLOZ-BJR3CP-20191210170814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 300611755
Report Date: 12/05/2019
Date Signed: 12/05/2019 05:39:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/20/2019 and conducted by Evaluator Gesine Connolly

PUBLIC

COMPLAINT CONTROL NUMBER: 06-CC-20190920111444

FACILITY NAME:	CAPISTRANO BEACH CITIES YMCA- PALISADES		FACILITY NUMBER:	300611755
ADMINISTRATOR:	FIZPATRICK, CAROLE		FACILITY TYPE:	840
ADDRESS:	26462 VIA SACRAMENTO		TELEPHONE:	(949) 496-1627
CITY:	CAPISTRANO BEACH	STATE: CA	ZIP CODE:	92624
CAPACITY:	90	CENSUS: 45	DATE:	12/05/2019
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Carole Fitzpartick		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Inadequate supervision resulting in injury to day care child.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Connolly made a subsequent inspection to this YMCA due to an allegation that inadequate supervision resulted in an injury to day care child was received in the licensing office 9/20/19.
Both portables Y-1 for older school age children and Y-2 for younger school age children were toured by the LPA. Census was taken. There were 23 school age children in Y-1 and 22 school age children in Y-2. There were 3 staff in Y-1 and 2 staff in Y-2. A review of criminal clearance records on this date indicates adults who require caregiver background checks have received criminal record and child abuse index clearances.
All children were actively engaged in the activities of the YMCA.

Continued on page two

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine Connolly	TELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 06-CC-20190920111444

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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- PALISADES	FACILITY NUMBER: 300611755
	VISIT DATE: 12/05/2019

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
26
27
28
29
30
31
32

page two
At the previous complaint inspection the director provided the following: headcount and attendance roster for 9/11/19 including the names of attending staff and a copy of a parent communication form dated 9/11/19. The YMCA was toured inside and outside, pictures were taken and at the time of the first inspection the director was interviewed.

During today's complaint inspection three additional staff were interviewed as well as four children. The tour of the facility and the interviews confirmed a child, while in care on 9/11/19, sustained an injury that was addressed by medical personnel. An unusual incident report regarding this injury has been submitted to licensing.

Interviews have been conducted to determine if there existed at this facility a lack of supervision: a lack of supervision resulting in the injury. It was determined that the injury occurred on the ramp that leads to the boys and girls bathrooms. It was determined staff remain positioned on the ramp leading to the bathrooms in order to provide visual supervision. It was also determined that direction was given by staff not to utilize the ramp railing for play. Interviews indicated staff witnessed the injury and provided first aid as needed.

An exit interview was completed. The report was reviewed and discussed. The director was informed that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is unsubstantiated.

In the areas that were evaluated no deficiencies were observed of the California Code of Regulation, Title 22, and Division 12 at the time of the inspections. 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.

Notice of Site Visit was posted. 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 penalties of $100.00. The 'Notice of Site Visit' must be posted on or adjacent to the door.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Gesine Connolly	TELEPHONE: (714) 293-9314
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2019

LIC9099 (FAS) - (06/04)

Page: 2 of 2