304370575-5-27-2022-06-CC-STOE-CETUAF-20220527152440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304370575
Report Date: 05/27/2022
Date Signed: 05/27/2022 03:24:48 PM

Document Has Been Signed on 05/27/2022 03:24 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 - DAVIS		FACILITY NUMBER:	304370575
ADMINISTRATOR:	LUGO, ALEISA		FACILITY TYPE:	840
ADDRESS:	1050 ARLINGTON DRIVE		TELEPHONE:	(714) 549-1882
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	75	CENSUS: 16	DATE:	05/27/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Andrea Hill, Director		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Stacy Torrence conducted an unannounced case management inspection, in response to a self-report Unusual Incident dated 05/16/2022. LPA met with Andrea Hill, Director. Census was taken. There was a total of 16 school-age children and 2 staff supervising. A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The self-reported incident on 05/16/2022 disclosed a staff slapped a child’s arm. During today’s inspection, LPA Torrence interviewed 2 staff and one child. Based on the interviews, Child 1 disclosed teacher hit C1's arm when C1 reached for a snack. Staff 1 disclosed C1 told her the teacher slapped C1’s arm while C1 was trying to reach for a snack. Staff 2 stated the staff member was terminated.

Based on LPA’s interviews, it was determined that a child’s personal rights was violated, in which, a staff member slapped C1 on the forearm while C1 was trying to reach for a snack and the following violation is being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 2 Section 101223(a)(3) Personal Rights, and is being cited on the attached LIC 809D.

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. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days and provide a copy to current and enrolling parents. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file.

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SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy Torrence	TELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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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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 - DAVIS	FACILITY NUMBER: 304370575
	VISIT DATE: 05/27/2022

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Exit interview was conducted. The Notice of Site Visit was posted. 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. Appeal Rights was explained. A copy of appeal rights (LIC 9058 1/16) will be provided through email and their signatures on this form acknowledges receipt of these rights. First level appeal is to Regional Manager, address is above on the report.

SUPERVISOR'S NAME: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy Torrence	TELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/27/2022 03:24 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 - DAVIS	FACILITY NUMBER: 304370575
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/31/2022 Section Cited	1 2 3 4 5 6 7	101223(a)(3) Personal Rights. (a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation ……….
	8 9 10 11 12 13 14	This requirement is not met as evidence by: Based on interviews, C1, and S1 disclosed a teacher hit C1 on the arm. This poses an immediate risk to the 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: Thuy Ho	TELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy Torrence	TELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC809 (FAS) - (06/04)

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