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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340311130
Report Date: 10/05/2023
Date Signed: 10/20/2023 09:36:20 AM


Document Has Been Signed on 10/20/2023 09:36 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/19/2023 04:11 PM

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

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This is an amended report on 10/20/2023 at 9:00a.m. to the unannounced, required- 1 year inspection conducted on 10/05/2023. There were 5 infants supervised by 2 staff. Report was reviewed and printed with facility representative Jessie Thomas.

At 2:40 a.m. on Thursday, October 5, 2023, Licensing Program Analyst (LPA) Pa Dao Vang met with Director, Kristina Gage, for the purpose of an unannounced, required - 1 year inspection. LPA observed a census of 5 infants awake supervised by 2 staff. There were 2 infants sleeping in the separate crib room. Facility hours of operation are from 7:00 a.m. - 6:00 p.m., Monday thru Friday. Center provide a.m, lunch and p.m snack for the children.

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 classroom, restrooms, and food service areas. LPA observed the following documents are posted: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, and menus. Director stated that there are no firearms nor poisons on the premises. LPA observed an expired fire drill log with the last date of 2/10/2023.

Infant formula is provided by parents/guardians. Center offers two snacks for children in the morning and afternoon. Other food in the facility was properly stored to prevent contamination in the fridge located in the front office room. Facility utilizes an electronic sign in and sign out program with a PIN through School Care Works.

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: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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 6


Document Has Been Signed on 10/06/2023 01:18 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 INFANT
FACILITY NUMBER: 340311130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, the licensee did not ensure that cleaning chemicals are inaccessible to children, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Director removed the bleach bottle immediately. Moving forward faciltiy will ensure cleaning chemicals are inaccessible to children. Director stated that the cleaning bottle was stored in the school age cabinets.
Request Denied
Type A
Section Cited
CCR
101429(a)(1)
Responsibility for Providing Care and Supervision for Infants
(1) Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. Under no circumstances shall ANY infant be left unattended.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not ensure sleeping infants are supervised at all times which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2023
Plan of Correction
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Director will train staff and send LPA a copy of the training outline with staff signatures to LPA's email (padao.vang@dss.ca.gov). Director will send a statement requesting more time to train staff to extend due date.
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: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 10/19/2023 04:14 PM

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 INFANT
FACILITY NUMBER: 340311130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
101174(d)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not ensure fire drill is done every 6 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
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Director will conduct fire drill and sent a photo of most recent log to LPA.
Deficiency Dismissed
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 2 staff files, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
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Director wil obtain required forms and store it in personnel files. LPA will return to review files.
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: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


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 INFANT
FACILITY NUMBER: 340311130
VISIT DATE: 10/05/2023
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LPA observed that each child had a Needs and Service plan. LPA observed an Individual Infant Sleep Plan (LOC9227) for each child under 12 months of age. LPA observed documentation that sleep checks were being conducted by staff every 15 minutes for all children under 2 years. Bottles and baby food were kept in refrigerator inside the classrooms and were properly labeled with the child’s name and date. All furnishings were in good condition. Infant diaper changing area is clean. Changing table was observed to be within arms reach from sink. There is a mat for the changing table with vinyl surface that is at least 1 inch think and has raised sides. Toys are appropriate size with no small parts for the safety of infants.

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.

Continue report on LIC 809-C...

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

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6
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 INFANT
FACILITY NUMBER: 340311130
VISIT DATE: 10/05/2023
NARRATIVE
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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 current AB 1207 Mandated Reporter training certificates, employee rights, and documentation of the educational background, training, and/or experience. There is at least 1 staff with current CRP/First Aid certification.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

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).

Facility Representative 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.

Continue Report LIC 809-C...

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

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
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 INFANT
FACILITY NUMBER: 340311130
VISIT DATE: 10/05/2023
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A deficiency is being cited based on LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D.

Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.



An exit interview was conducted and Plans of Correction were reviewed and developed with the Director Kristina Gage. A copy of this report and appeal rights were discussed and left with Licensee. A notice of site visit was provided and posted by LPA and must remain posted for 30 days.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Dao VangTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6