343603160-9-30-2021-03-CC-SDLA-C7LPSM-20211008113433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 343603160
Report Date: 09/30/2021
Date Signed: 09/30/2021 01:27:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/03/2021 and conducted by Evaluator Tanya Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 03-CC-20210803162417

FACILITY NAME:	YMCA OF SUPERIOR CALIFORNIA - COSUMNES RIVER ELE.		FACILITY NUMBER:	343603160
ADMINISTRATOR:	BROWN, AUBRIE		FACILITY TYPE:	840
ADDRESS:	13580 JACKSON ROAD		TELEPHONE:	(916) 208-7732
CITY:	SLOUGHHOUSE	STATE: CA	ZIP CODE:	95683
CAPACITY:	73	CENSUS: 7	DATE:	09/30/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Alexis Keys		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff do not provide adequate

INVESTIGATION FINDINGS:

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On 09/30/2021 at 11:15 AM, LPA Washington met with Head Teacher Alexis Keys to deliver complaint finding for the allegation above. Upon arrival, LPA observed seven students in care of Alexis Keys. Facility Representative, Aileen Flores arrived to the facility at 11:50 AM and assisted LPA with the remainder of the visit.
Reporting Party alleged that staff do not provide adequate supervision to children in care and a child was able to leave the classroom unsupervised several times due to lack of supervision.
During the course of the investigation, LPA conducted interviews with the Reporting Party, staff and some parents of currently enrolled children. LPA also conducted review of facility files and made observations.
Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 03-CC-20210803162417

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 - COSUMNES RIVER ELE.	FACILITY NUMBER: 343603160
	VISIT DATE: 09/30/2021

NARRATIVE

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During the interviews with staff LPA learned that there was a child in care with difficult behavior who would at times sneak out of the classroom without teachers knowledge. Staff indicated that at times Child #1 left the classroom three times a day if something upset them.
During the records review, LPA has reviewed incident reports pertaining to Child #1. LPA learned that Child #1 was without visual supervision on at least one occasion. Incident report dated 11/20/2020 states that staff were looking for Child #1 for at least 20 minutes. After the child was located Child #1 still refused to return to class. Staff indicated that Child #1s parent was contacted when these incidents occurred.

Based on interviews with staff and records review the allegation of lack of supervision is substantiated.

Upon receipt, facility representative shall post and provide copies of this licensing report to parents/ guardians of children who are currently enrolled as well as parents/ guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must acknowledge receipt of this report and citation by signing a LIC9224, “ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS”. A copy of this form should be placed in each child file upon receipt from parent.
LPA discussed this report with facility representative and conducted an exit interview. LPA also provided appeal rights. Notice of site visit posted.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

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Control Number 03-CC-20210803162417

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 - COSUMNES RIVER ELE.	FACILITY NUMBER: 343603160
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/01/2021 Section Cited CCR 101229(1)	1 2 3 4 5 6 7	No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.	1 2 3 4 5 6 7	Facility Representative will come up with a written plan of correction and submit proof of correction to LPA by POC date of 10/01/2021. tanya.washington@dss.ca.gov
	8 9 10 11 12 13 14	This requirement is not met as evidenced: LPA learned that Child #1 was without direct visual supervison on at least one occasion for 20 minutes. This is an immeidate danger to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

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