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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311129
Report Date: 09/19/2019
Date Signed: 09/19/2019 03:12:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:YMCA OF SUPERIOR CALIFORNIA- CDC PRESCHOOLFACILITY NUMBER:
340311129
ADMINISTRATOR:FUGATE, NANCYFACILITY TYPE:
850
ADDRESS:2021 W STREETTELEPHONE:
(916) 452-9622
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:61CENSUS: 51DATE:
09/19/2019
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Nancy FugateTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Goodell met with Director Nancy Fugate for an unannounced Annual Inspection. The Facility’s hours of operation are Monday-Friday, 6:30am-6:00pm. Staff members present during inspection obtained finger-print clearance through Community Care Licensing. LPA toured the facility including all activity/classroom areas, food service area and restrooms. Upon arrival children and staff were preparing for nap. LPA observed 12 children with 1 staff member in the 2's class, 17 children with 2 staff in the 3-4 year old area and 22 children with two staff in the 4-5 year old area. LPA observed several dirt stains, dried play dough and paint on the carpet located in the 3-4 preschool activity area. Director facility recently received new rugs and will request carpet clean.

Facility provides breakfast, lunch and afternoon snack. LPA observed a current menu and acitvity schedule posted. LPA observed that outdoor activity space and playground equipment. LPA observed several food wrappers, napkins and debris in the outdoor play yard and accessible to children. Director stated staff will conduct a sweep and clean up yard. Drinking water is made readily available to children both indoors and outdoors with individual water bottles. LPA observed cleaning compounds are inaccessible to children. LPA observed that medications are centrally stored and inaccessible to children. LPA observed napping equipment and director stated napping sheets are washed weekly. LPA reviewed children’s files and records such as Identification and Emergency Information (LIC 700). LPA also reviewed staff's educational background /transcripts and staff have qualifications that meet the educational requirements. LPA observed that at least one staff member present during today’s inspection has a current Pediatric CPR/First Aid that expires on 5/11/21.

Community Care Licensing website www.ccld.ca.gov, provide for the facility to obtain updated licensing information, new regulations, self-assessment guides, and access forms. LPA advised the director of their responsibility to stay current in regards to new regulations.

Title 22 Deficiencies cited on next page. An exist interview was conducted and appeal rights were issued. Notice of Site Visit issued and the AD understands it must remain posted for 30 days.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kristal GoodellTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2019
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: YMCA OF SUPERIOR CALIFORNIA- CDC PRESCHOOL
FACILITY NUMBER: 340311129
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2019
Section Cited

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Indoor Activity Space. All floors shall be safe and clean. This requirement is no met due to LPA observed several dirt stains, dried play dough and paint on carpet in the preschool room.
Type B
09/23/2019
Section Cited

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Outdoor Activity Space. The surface of the outdoor activity space shall be maintained: Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard.This requirement was not met due to LPA observed several food wrappers, napkins and debris in the outdoor play yard and accessible to children.

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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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Kristal GoodellTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2019
LIC809 (FAS) - (06/04)
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