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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311130
Report Date: 09/19/2019
Date Signed: 09/19/2019 03:16:28 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 INFANTFACILITY NUMBER:
340311130
ADMINISTRATOR:FUGATE, NANCYFACILITY TYPE:
830
ADDRESS:2021 W STREETTELEPHONE:
(916) 452-9622
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:12CENSUS: DATE:
09/19/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Nancy FugateTIME COMPLETED:
03:45 PM
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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 6:30-6:00pm. LPA conducted a census of 4 awake children with two staff and one volunteer in the infant activity area. LPA also observed 7 children in the infant napping area with one staff member. Staff members present have obtained fingerprint clearance through community care licensing. Director acknowledged that volunteers are not to be counted in ratio or left alone with children.

Facility provides breakfast, lunch and afternoon snack. LPA observed a current menu and activity posted in the entrance of the classroom. LPA toured activity/classroom areas, furniture, equipment, food service area and restrooms. LPA also toured outdoor area. Director stated drinking water is available for children with individual sippy cups. LPA observed sign/in-sign/out sheets. LPA observed two changing tables located near a sink. LPA observed infant bottles labeled and dated. Director stated milk and food are returned to parents daily. LPA observed the infants nap equipment. Director stated napping sheets are washed daily. Director acknowledged that the nap area is separate from the activity area and direct supervision is required in that room. LPA observed fire extinguisher 3A40BC, smoke and carbon monoxide detectors.

LPA reviewed children files. Documents included Identification and Emergency Information (LIC700) and the Infant’s Needs and Services Plan. LPA observed child roster and fire drill log. LPA reviewed staff files. LPA observed at least one staff member present during today’s inspection has current Pediatric CPR/First Aid that expires in 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.

No Title 22 Deficiencies cited. An exist interview was conducted and report was reviewed with AD. Notice of Site Visit issued and the director 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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