<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613958
Report Date: 09/16/2022
Date Signed: 09/16/2022 03:08:46 PM


Document Has Been Signed on 09/16/2022 03:08 PM - It Cannot Be Edited

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 - LOMA VISTA SCHOOLFACILITY NUMBER:
300613958
ADMINISTRATOR:ISABEL SALGADOFACILITY TYPE:
840
ADDRESS:13822 PROSPECT AVE.TELEPHONE:
(714) 730-0541
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:92CENSUS: 22DATE:
09/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Isabel Salgado - DirectorTIME COMPLETED:
03:00 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
A case management inspection was conducted today by Licensing Program Analyst (LPAs), Odom who met with the Director, Isabel Salgado. A self-report incident by the facility was received at the regional office on 6/3/22 which stated that child #1 was left in the restroom and was not supervised for 2-3 minutes.

Census was taken today and there was a total of 22 school age children with a total of 7 staff members. A review of criminal record clearances indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

During this investigation, LPA interviewed 2 staff, 1 child and obtained a copy of the children roster, personnel report, and took pictures. From the interviews conducted it was discovered that on 6/2/22 at around 3:00pm right before snack time children went to the restroom as group, while Staff #1’s classroom was utilizing the restroom S1 returned from break and Staff #3 was released from breaking S1. S1 assumed all children were done with the restroom and waiting in line. S1 walked to the outdoor benches which is located 36 feet away from the restroom, about 1-2 minutes C1 came out the restroom and walked to the outdoor benches. LPA interviewed C1 and C1 disclosed S1 was not outside the restroom they were at the benches.

Based on the information gathered from the interviews conducted, observation and records reviewed. It was determined that C1 was left in the restroom unsupervised for about 1-2 minutes.

The facility was not in compliance of the California Code of Regulations, Title 22, Division 12. The following citation Responsibility for Providing Care and Supervision section 101229(a)(1) was issued today on the attached LIC 809D.

This report cites Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

Continue to page 2.

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
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 3


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 - LOMA VISTA SCHOOL
FACILITY NUMBER: 300613958
VISIT DATE: 09/16/2022
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 2
Exit interview was conducted. Notice of Site Visit was posted during the visit. Director Isabel Salgado 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. Appeal rights provided and explained. The Director was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/16/2022 03:08 PM - It Cannot Be Edited

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 - LOMA VISTA SCHOOL
FACILITY NUMBER: 300613958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
Section Cited

1
2
3
4
5
6
7
Care and Supervision 101229(a)(1): No child(ren) 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).
This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on interviews it was disclosed C1 was left in the restroom unsupervised for about 1-2 minutes. This is an immediate risk to the health and safety of children in care.
8
9
10
11
12
13
14

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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3