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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 372005393
Report Date: 05/31/2023
Date Signed: 05/31/2023 01:51:15 PM


Document Has Been Signed on 05/31/2023 01:51 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108



FACILITY NAME:TOBY WELLS YMCA - HOLMES ELEMFACILITY NUMBER:
372005393
ADMINISTRATOR:FLENT ADLEANFACILITY TYPE:
840
ADDRESS:4902 MOUNT ARARAT DRIVETELEPHONE:
(858) 496-8110
CITY:SAN DIEGOSTATE: CAZIP CODE:
92111
CAPACITY:125CENSUS: DATE:
05/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Director/Site Supervisor Kevin StarlingTIME COMPLETED:
01:55 PM
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On 5/31/2023, Licensing Program Analysts, Joelle Redding and Gerald Poindexter, made an unannounced visit to follow up on a self-reported incident that occurred on 4/19/23 wherein a child (Child #1) fell from the play structure, sustaining an injury.

LPAs examined the area of the fall, inspected the cushioning, interviewed staff present at the time of the incident, Child #1 and potential witnesses. Child #1 described the incident as the facility reported it. There were 2 staff members with 16 children at the time of the incident.

Based upon information obtained today, staff directly observed the fall but was unable to intervene quickly enough to prevent it. The facility has appropriate cushioning, age appropriate equipment, direct supervision was in place, ratios were met and staff responded appropriately with first aid and limited activity as a precaution. The extend of the injury was not immediately apparent and was not diagnosed until the following day. Children were reminded about safe play on the structure prior to each time they play and the rules were reinforced after the incident.

No deficiencies are cited.
SUPERVISOR'S NAME: Renesha AskewTELEPHONE: (619) 767-2155
LICENSING EVALUATOR NAME: Joelle ReddingTELEPHONE: (619) 767-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
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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