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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343603160
Report Date: 10/25/2021
Date Signed: 10/26/2021 01:29:53 PM

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 - COSUMNES RIVER ELE.FACILITY NUMBER:
343603160
ADMINISTRATOR:BROWN, AUBRIEFACILITY TYPE:
840
ADDRESS:13580 JACKSON ROADTELEPHONE:
(916) 688-8660
CITY:SLOUGHHOUSESTATE: CAZIP CODE:
95683
CAPACITY:73CENSUS: 0DATE:
10/25/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jen Moore, Alexis Keys and Ramon GarciaTIME COMPLETED:
10:40 AM
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On October 25, 2021 at 10:15 AM, Licensing Program Manager Seychelle De Luca and Licensing Program Analyst Tanya Washington conducted a scheduled Teams meeting with Senior Youth Development Director, Jen Moore, Site Supervisor, Alexis Keys and Youth Development Coordinator, Ramon "Ray" Garcia.

The reason for this informal meeting is to discuss a recent Type A violation for absence of supervision which was cited on 09/30/2021. LPM defined the difference between Non-Compliance and an Informal meeting. LPM advised that the purpose of today's meeting is to help the facility gain compliance.

On 08/03/2021, Community Care Licensing office received a complaint alleging staff do not provide adequate supervision to children in care. During the investigation LPA has learned that a child who was previously enrolled in the facility had eloped from staff and was without direct visual supervision on multiple occasions. During these occasions, staff searched for this child on school campus and eventually located the child each time. Facility staff also failed to report those incidents to the licensing office as required per unusual incident reporting on form LIC624.

Jen Moore stated the following steps are taken to correct the citation:
- The entire organization received re-training on active supervision and better communication.
- Current Site Supervisor was trained to report unusual incidents to management as well as licensing office.

In lieu of Director's signature, LPA will email this report and Director will respond via email as verification of receipt.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2021
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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