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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334843786
Report Date: 11/15/2019
Date Signed: 11/15/2019 10:53:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:CORONA-NORCO FAMILY YMCA-YMCA CENTER AT JURUPAFACILITY NUMBER:
334843786
ADMINISTRATOR:MONICA HUNTERFACILITY TYPE:
830
ADDRESS:9254 GALENA STREETTELEPHONE:
(951) 736-9622
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:14CENSUS: 11DATE:
11/15/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Martha Voeltz, DirectorTIME COMPLETED:
11:10 AM
NARRATIVE
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During Complaint Investigation visit, LPA Wong was informed the facility failed to report the incident where Child #1 sustained an injury that required medical attention. The Director stated the parent was provided with an "Ouch" report but failed to submit an Unusual Incident Report (UIR) to CCL as required, pert Title 22.


See LIC809D for cited deficiencies. Appeal rights were discussed and a copy was provided.

An exit interview was conducted and a copy of this report was provided this date.
SUPERVISOR'S NAME: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Marlene WongTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CORONA-NORCO FAMILY YMCA-YMCA CENTER AT JURUPA
FACILITY NUMBER: 334843786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2019
Section Cited

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REPORTING REQUIREMENTS:

Upon the occurrence, during the operation of the child care center, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information
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shall be submitted to the Department within seven days following the occurrence of such event, which includes any injury to any child that requires medical treatment. This requirement was not met as evidenced by: LPA Wong confirmed that the facility failed to report incident involving Child #1 to CCL.
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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: Kimberly WilliamsTELEPHONE: (951) 248-0228
LICENSING EVALUATOR NAME: Marlene WongTELEPHONE: (951) 204-4847
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2019
LIC809 (FAS) - (06/04)
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