<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311130
Report Date: 10/20/2022
Date Signed: 10/20/2022 04:38:07 PM


Document Has Been Signed on 10/20/2022 04:38 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
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: 7DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tiffany Davidson and Melia Savage TIME COMPLETED:
04:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Alize Tillery met with Licensee Rep Tiffany Davidson and Director Melia Savage 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 2 awake infant children, and 3 napping infants, supervised by 3 staff. Facility hours of operation are Monday through Friday from 6:30 AM to 6:00 PM.

LPA toured all activity and classroom spaces (Infant Room), the kitchen area, the napping area and the outdoor play area. Program is documenting the napping infants, every 15 minutes. In the napping area, LPA observed 2 infants in sleep sacks. LPA informed Director that a waiver request will need to be submitted in order for a child to be considered to use a sleep sack/suit while in care. LPA also informed Director that cribs should not be used as a storage space. LPA observed the following documents are posted: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, menus, and daily schedule. Cleaning disinfectants, medications and hazardous items are appropriately stored and inaccessible to children. Director stated there are no poisons, weapons or bodies of water 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 personal cups. LPA observed the facility’s sign in and out system. 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 the building.

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: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
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: 10/20/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
6 staff files and 5 present day care children file records were reviewed. All children and staff files were observed to be complete. LPA observed children’s individual sleep plan and needs and services plan. At least one staff member present today has current Pediatric CPR and First Aid certification. All staff currently employed with the facility have a criminal record clearance. 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.

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.



This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. 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

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 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.

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

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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
VISIT DATE: 10/20/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Tillery informed Director that this report dated 10/20/2022 document(s) 1 Type A citation. Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Tillery informed the Director to provide a copy of this licensing report dated 10/20/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

The deficiency is cited on the following 809D page. A notice of site visit was given and must remain posted for 30 days.



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

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/20/2022 04:38 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
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: 10/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101430(a)(3)(C)
(C) An infant shall not be swaddled while in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based onobservation, the licensee did not comply with the section cited above in that LPA Tillery observed two infants sleeping in the crib with sleep sacks on, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
1
2
3
4
Director will submit a correspondence to LPA Tillery, stating she understands that sleep sacks are not to be allowed without an approved waiver. Director will submit a waiver request to LPA Tillery.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4