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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311129
Report Date: 11/23/2021
Date Signed: 11/23/2021 01:32:17 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) 457-9622
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:61CENSUS: 21DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Melia SavageTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Alize Tillery and Mikah Martinez met with Acting Director Melia Savage for the purpose of an unannounced required 1 year annual inspection. Upon arrival, LPA observed 21 preschool children, supervised by 4 staff. The facility hours of operation are Monday through Friday from 6:30 AM to 6:00 PM.

LPAs toured all activity and classroom spaces, restrooms and one outdoor play area. LPAs observed preschool children utilizing the school age room. Acting Director stated that the facility has not had school age children since March 2020. Acting Director understands preschool children are to not use the school age room until inspected and granted for use by the Fire Department and Licensing. LPA observed the following documents are posted: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, and daily schedule. Cleaning disinfectants, medications and hazardous items are appropriately stored and inaccessible to children. Director stated there are no poisons or firearms on the premises. Furniture and equipment are in good condition, and toileting facilities are in safe, sanitary and operating condition. LPAs observed stained carpets and ripped mats. Acting Director stated that the facility will document when there is a deep clean of the carpets. The program provides breakfast, lunch and a pm snack.



Drinking water is readily available to children both indoors and outdoors. Director stated that children bring their own drinking water bottles, which are used both indoors and outdoors. LPAs observed the facility’s sign in and out sheet and a complete Children’s Roster on file. Playground equipment and surfaces are free of loose or sharp parts. There are sufficient equipment and toys. There are shaded areas supplied by the building and trees.

Report continues on 809-C.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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, 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: 11/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that Acting Director confirmed that the facility does not have a carbon monoxide detector which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2021
Plan of Correction
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Director will send LPA Tillery proof of a fuctioning carbon monoxide detector by plan of correction date.
Type B
Section Cited
CCR
101174(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in that acting director confirmed that the facility has not conducted any fire drills, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2021
Plan of Correction
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Director will send LPA Tillery proof of a completed and documented fire drill by plan of correction date.
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: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2021
LIC809 (FAS) - (06/04)
Page: 2 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: YMCA OF SUPERIOR CALIFORNIA- CDC PRESCHOOL
FACILITY NUMBER: 340311129
VISIT DATE: 11/23/2021
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All staff and 10 children's records were reviewed. Each child's file was observed to be complete. At least one staff member present today has a current Pediatric CPR and First Aid certification. LPAs observed complete staff files. LPAs provided the “Director Checklist” and “Licensee Representative Checklist”. LPAs reminded Director that 100% supervision is required at all times. LPAs observed a smoke detector and fire extinguisher. Acting Director stated that the facility does not have a carbon monoxide detector. LPA reviewed the Department's inspection authority and discussed with designee any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within ten working days.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.


Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA is provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm



Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A notice of site visit was given and must remain posted for 30 days. Deficiencies are cited on the following, 809D page.

Exit interview conducted and report was reviewed with the Acting Director, Melia Savage.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3