300611755-7-19-2021-06-CC-RJCN-C53RUT-20210719132027

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300611755
Report Date: 07/19/2021
Date Signed: 07/19/2021 01:20:43 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- PALISADES		FACILITY NUMBER:	300611755
ADMINISTRATOR:	FAULS-RIVAS, TYLER		FACILITY TYPE:	840
ADDRESS:	26462 VIA SACRAMENTO		TELEPHONE:	(949) 496-1627
CITY:	CAPISTRANO BEACH	STATE: CA	ZIP CODE:	92624
CAPACITY:	90	CENSUS: 16	DATE:	07/19/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Tyler Fauls-Rivas		TIME COMPLETED:	01:30 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 Analysts (LPAs) Ryan Chan and Lou Vanzant conducted an onsite inspection for the purpose of a 1-year required inspection. LPAs met with Director Tyler Fauls-Rivas who took LPAs on a tour of the inside and outside of the facility and the floor and yard plan (LIC 999) was verified. Census was taken in individual classrooms. The overall census observed was 3 staff and 16 school aged children. Due to COVID 19 guidelines, LPA observed staff and children wearing face mask, social distancing and following CDC and Dept of Public Health Guidelines. During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. Facility hours are 6:45a.m.- 6:00p.m., Monday through Friday. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During the inspection of the indoor activity space, items which could pose a danger to children (detergents, cleaning compounds, and medications) were observed to be stored out of the reach of children. Poisons/Hazardous Items are not kept on the premises. Food is prepared on site; morning and afternoon snacks are provided, children bring their own lunches. Food prep areas were clean and sanitary. Food is properly stored. Menus were posted where they could be reviewed by parents. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. There is drinking water available to children indoors via water cooler and disposable cups or children bring their water bottles which can be refilled as needed. The children's bathrooms are clean and sanitary. The facility has conducted an emergency drill within the past six months. The facility has a working carbon monoxide detector and fire extinguisher. Facility met all posting requirement. Continued on page 2

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

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- PALISADES	FACILITY NUMBER: 300611755
	VISIT DATE: 07/19/2021

NARRATIVE

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Staff files were reviewed for staff present during the facility inspection on this date, 3 staff files were reviewed. Health screening and immunizations as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1596.8662(b)(1) states, a person shall not be employed or volunteer at a child care center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for 3 staff reviewed were within compliance. Staff have written declaration to decline flu vaccine. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporter training, and to renew the training every two years, staff #3 did not have proof of renewal of mandated reporter training. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 10/10/22.

The director was informed that the Criminal Record Statement (LIC 508) has been updated, and the facility must now use the new form with revised date 7/20. Director was also informed that the LIC 508 must be submitted with all Criminal Background Clearance.

Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of 8 children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700) and a medical assessment. In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed and was within compliance.

LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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

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SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

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- PALISADES	FACILITY NUMBER: 300611755
	VISIT DATE: 07/19/2021

NARRATIVE

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The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at least four feet in height.
The surface of the outdoor activity space was well maintained and free of hazards. This facility is located on a school campus, outdoor space is a large grassy area and tarmac with basketball courts and volleyball courts for children to use. Drinking water in the outdoor activity space is provided by water cooler and disposable cups or children bring their water bottles.
There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair.

The director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov, director may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov or at www.ccld.ca.gov. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The director was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative.

PIN 21-08-CCLD announces the resumption of on-site mandated regular inspections, also known as “annual inspections. Please post/keep this PIN in the facility/home where parents, authorized representatives, and children in care can easily access it and distribute the Companion Guide PIN Summary for Children in Care Fact Sheet (located at the end of the PIN) to their authorized representative. LPA provided (licensee/director) a copy of the PIN. (Continued on page 4)

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

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- PALISADES	FACILITY NUMBER: 300611755
	VISIT DATE: 07/19/2021

NARRATIVE

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Based on LPAs records reviewed, the following violation was observed and is being cited in accordance with Health and Safety Code Section 1596.8662(b)(1), see attached LIC 809D.

§1596.8662 Availability of information regarding detecting and reporting child abuse and neglect; training for mandated reporter who is licensed day care provider, administrator, or employee of a licensed child day care facility; proof of completion
(b) (1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

An Inspection and exit interview was completed with director. The report was reviewed and discussed. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

LIC809 (FAS) - (06/04)

Page: 4 of 5

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- PALISADES	FACILITY NUMBER: 300611755
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/02/2021 Section Cited	1 2 3 4 5 6 7	1596.8662(b)(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provide...shall complete the mandated reporter training...renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on records reviewed staff #3 did not have proof of renewal of mandated reporter training which poses a potential risk to the health and safety of children in care.	8 9 10 11 12 13 14
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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: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

LIC809 (FAS) - (06/04)

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