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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311130
Report Date: 08/25/2021
Date Signed: 08/26/2021 08:28:28 AM

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:GAGE, KRISTINAFACILITY TYPE:
830
ADDRESS:2021 W STREETTELEPHONE:
(916) 457-9622
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY:12CENSUS: 4DATE:
08/25/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Kristina Gage TIME COMPLETED:
02:15 PM
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On Wednesday, August 25, 2021, at approximately 1:15pm, Licensing Program Analysts (LPAs) Alize Tillery and Karyn Guerra met with Director, Kristina Gage for a plan of correction inspection regarding deficiencies cited on 07/28/2021. LPAs observed 4 children supervised by 2 staff in the infant room.

LPAs reviewed staff files and observed S3 immunization record and all staff had current Mandated Reporter Training certificates.

Today, LPAs are clearing citation 1596.7995(a)(1) and 1596.8662(b)(1).


An exit interview was conducted and notice of site visit posted, Director acknowledges it will be posted for 30 days.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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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