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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311129
Report Date: 11/08/2023
Date Signed: 11/08/2023 01:35:09 PM


Document Has Been Signed on 11/08/2023 01:35 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:YMCA OF SUPERIOR CALIFORNIA - CDC PRESCHOOLFACILITY NUMBER:
340311129
ADMINISTRATOR:MELIA SAVAGEFACILITY TYPE:
850
ADDRESS:2021 W STREETTELEPHONE:
(916) 457-9622
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:61CENSUS: 25DATE:
11/08/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tiffany Davidson and Jessica ThomasTIME COMPLETED:
02:00 PM
NARRATIVE
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At 9:00 a.m. on Wednesday, November 8, 2023, Licensing Program Analyst (LPA) Pa Dao Vang met with Facility Representative, Tiffany Davidson, and Director Jessica Thomas for the purpose of an unannounced, required - 1 year inspection. A census was conducted at 9:15 a.m. LPA observed 25 preschool children supervised by 4 staffs. Facility hours of operation are from 7:00 a.m. - 6:00 p.m., Monday thru Friday.

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.


LPA conducted a health and safety inspection of the classrooms, restrooms, and food service areas. LPA observed the following documents are posted: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, Lead Poising information, menu, and daily schedule. Cleaning disinfectants and hazardous items are appropriately stored and inaccessible to children. Director stated that there are no firearms nor poisons on the premises.

Center offers a lunch, and two snacks for children in the morning and afternoon. LPA observed 2 milk gallons with overdue date of 11/5/2023 stored in each classroom refrigerators. Staff in each classroom immediately threw out the milks. Facility utilizes a sign in and sign out blinder located in the entrance room for parents. LPA observed several forms with initials and others with full signatures from parents.

Continue report on LIC809-C...

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Dao VangTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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 4


Document Has Been Signed on 11/08/2023 01:35 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: YMCA OF SUPERIOR CALIFORNIA - CDC PRESCHOOL
FACILITY NUMBER: 340311129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2023
Section Cited
CCR
101227(1)

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101227 Food Serices
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the children...All food shall be selected, stored, prepared and served in a safe and healthful manner.
This requirement is not met as evidenced by:
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Director will assign closing & opening staff to check the refrigerators for overdue milks and disgard them. Director will email LPA at padao.vang@dss.ca.gov with the copy of the opening and closing procedures with staff names assigned to duties.
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Based on observation and interview, the facility representative did not ensure overdue milk gallons were disgarded, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
12/08/2023
Section Cited
CCR1596.7995(a)(1)

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1596.7995(a)(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles....

This requirement is not met as evidenced by:
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Staff will locate MMR & Tdap records. Director will email LPA at padao.vang@dss.cs.gov proof of immunizations records.
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Based on observation, interview, record reviews, the facility representative did not comply with the section cited above in 1 out of 4 staff files did have MMR & Tdap in file, which posed a potential health, safety or personal rights risk to persons in care.
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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: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Dao VangTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: YMCA OF SUPERIOR CALIFORNIA - CDC PRESCHOOL
FACILITY NUMBER: 340311129
VISIT DATE: 11/08/2023
NARRATIVE
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Facility provides Incidental Medical Services. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. The following information regarding ADA was 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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Napping logs were observed.

LPA conducted a health and safety inspection of the outdoor space. Playground equipment and surfaces were free of loose or sharp parts. Outdoor shade was provided by canopies. Water is accessible via labeled bottles.

LPA reviewed staff and children's records. Each child's file contained an admission agreement, emergency card, health history, immunization, and acknowledgement of receipt of personal rights, consent for emergency medical treatment, and parent’s rights. LPA observed CPR and First aid certification for at least one staff on the facility premises. LPA observed staff missing TDAP and MMR in personnel file.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.



Continue report on LIC809-C...
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Dao VangTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: YMCA OF SUPERIOR CALIFORNIA - CDC PRESCHOOL
FACILITY NUMBER: 340311129
VISIT DATE: 11/08/2023
NARRATIVE
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Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Title 22 deficiencies are cited on the subsequent pages of this report. An exit interview was conducted with the Director, Jessica Thomas. Appeal rights and a notice of site visit were provided. Notice of site visit shall remain posted for a period of 30 days.

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

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4