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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613958
Report Date: 06/13/2022
Date Signed: 06/13/2022 04:04:18 PM


Document Has Been Signed on 06/13/2022 04:04 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:DORAIN CASSELLFACILITY TYPE:
840
ADDRESS:13822 PROSPECT AVE.TELEPHONE:
(714) 730-0541
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:92CENSUS: 61DATE:
06/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Isabel Salgado - DirectorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Carmen Odom conducted an unannounced case management incident inspection in response to a self-report Unusual Incident dated 6/3/2022. LPA met with Director Isabel Salgado. LPA observed 61 school age children playing outside with 5 staff. A review of staff criminal clearance 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 or exemptions.

On 6/3/2022 an self-reported Unusual Incident Report (UIR) was filed with the Licensing Office. The facility reported that child #1 was left in the restroom and was not supervised for 2-3 minutes. During today’s visit, LPA obtained an updated copy of the children’s roster, personnel report, took pictures, obtained staff records and interviewed director, 1 staff, and 1 child. Due to insufficient information available at this time, the reported incident needs further investigation.

Exit interview was conducted. The Notice of Site Visit was posted. 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.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Carmen OdomTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
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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