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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311130
Report Date: 07/28/2021
Date Signed: 07/28/2021 05:44:24 PM

COMPREHENSIVE INSPECTION
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) 457-9622
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:12CENSUS: 8DATE:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Kristina Gage TIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Alize Tillery and Gagan Singh met with Director Kristina Gage for the purpose of an unannounced annual random inspection. Director was reminded never to exceed the conditions, limitations and capacity specified on the license. Upon arrival, LPA observed 4 awake infant children supervised by 2 staff members in the in the infant room, and 4 sleeping infant children with 1 staff member in the napping area. Facility hours of operation are Monday through Friday from 6:30 AM to 6:00 PM.

LPA toured all activity and classroom spaces, the kitchen area, the napping area and the outdoor play area. LPA observed the following documents are posted: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, menus, and daily schedule. Cleaning disinfectants, hazardous items, and medications are appropriately stored and inaccessible to children. Director stated there are no poisons on the premises. Furniture and equipment are in good condition, and toileting facilities are in safe, sanitary and operating condition. LPA observed one changing table in arms reach of a sink. LPA observed infant food and bottles labeled in the refrigerator. The floors appeared clean throughout the facility. The food preparation space is free of litter, all food was protected against contamination, and storage containers with solid waste have covers.



Drinking water is readily available to children both indoors and outdoors. LPA observed a water pitcher and children’s cups that are accessible to children. LPA observed full legal signatures while reviewing the sign in and sign out sheet. Playground equipment and surfaces are free of loose or sharp parts. There is rubber cushion beneath the playground equipment in the outdoor play area. There are sufficient equipment and toys. There are shaded areas supplied by overhangs.

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: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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 4
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 INFANT
FACILITY NUMBER: 340311130
VISIT DATE: 07/28/2021
NARRATIVE
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Four staff files and all present day care children file records were reviewed. Two daycare children have incomplete Physician’s Report (LIC 701). At least one staff member present today has current Pediatric CPR and First Aid certification (exp. 07/2022). All staff currently employed with the facility have a criminal record clearance and health screening reports. LPA observed that staff are missing Mandated Reporter Training certificates. LPA observed that one staff member is missing their immunization record. There are no firearms or bodies of water on the premises. LPA observed a smoke and 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. LPA verified the annual fees are current.

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 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.

This facility evaluation report was reviewed and discussed with Director. A Notice of Site Visit was provided and should remain posted for a period of 30 days for parental review. Director was encouraged to visit the Department's website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining child care centers. An exit interview was conducted.



A deficiency is cited on the subsequent page of this report under the California Code of Regulations, Title 22. Director was provided a copy of the Appeal Rights (LIC9058) and Director's signature on this form acknowledges receipt of these rights.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: YMCA OF SUPERIOR CALIFORNIA- CDC INFANT
FACILITY NUMBER: 340311130
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2021
Section Cited

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(b)(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years
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following the date on which he or she completed the initial mandated reporter training.
This requirement has not been met evidenced by: LPA did not observe current Mandated Reporter Training certificates during the file reviews. This poses an potential risk to children in care.
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Type B
08/25/2021
Section Cited

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(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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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This requirement has not been met, evidenced by: LPA did not oberve immunization records for S3. S3 has been employed since December 2020. This poses a potential risk to children in care.
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Director will obtain immunization record from S3 before plan of correction date 8/25/2021.
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: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: YMCA OF SUPERIOR CALIFORNIA- CDC INFANT
FACILITY NUMBER: 340311130
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2021
Section Cited

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(f) Cribs shall be free from all loose articles and objects, including blankets and pillows.
This requierment was met, evidenced by:
LPA observed 4 napping infants with blankets. This poses an immediate health and safety risk to children 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: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2021
LIC809 (FAS) - (06/04)
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