376105068-8-18-2021-51-CC-SCLA-C5ZQDU-20210818120519

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 376105068
Report Date: 08/18/2021
Date Signed: 08/18/2021 12:06:11 PM

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:	YMCA TEENS IN MOTION: RANCHO BERNARDO HIGH		FACILITY NUMBER:	376105068
ADMINISTRATOR:	LUCELYNA GODWIN		FACILITY TYPE:	840
ADDRESS:	13010 PASEO LUCIDO		TELEPHONE:	(619) 873-7134
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY:	30	CENSUS: 0	DATE:	08/18/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lucelyna Godwin & Tess Williams		TIME COMPLETED:	11:00 AM

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	On 08/18/2021 at 10:00am, Licensing Program Analyst (LPA), Samantha Clenista conducted an announced Pre-Licensing inspection. LPA met with Tess Williams (Center Director), Lucelyna Godwin (Association Program Specialist) and Shelby Gomez (Executive Manager). A tour of the facility was conducted. This program will operate in bungalow E14 located at Rancho Bernardo High School. A fire clearance was granted on 07/26/2021. The program will use the bathrooms (girls and boys) located across the counseling center that afford privacy. Per Health and Safety Code Sections 1596.806(a), (a)(1), (1)(2) and (d) this program is exempt from square footage, fencing, outdoor activity space, toilet and isolation requirements. Outdoor play area includes grassy quad located near the center of the school. Ms. Williams stated that the staff will also go on walks around the school for additional outdoor activities. The room is equipped with tables and chairs and age appropriate equipment and activities. Drinking water is readily accessible via water cups and refillable water jugs. Ms. Williams stated that medications will be kept in a locked box and inaccessible to children. Classroom also has a complete first aid kit, operational refrigerator and carbon monoxide detector. There are snacks in the storage closet, which will be prepared in the classroom. Classroom has a storage cabinet for cleaning supplies which are made inaccessible via lock. A separate restroom (men and women) is available and provides privacy when in use. Sign-in area is located directly left of entering the classroom. All COVID-19 posters are posted. COVID-19 self-assessment guide was received and reviewed during inspection. Facility representatives were reminded to keep anything that reads, “Keep Out of Reach of Children” to be inaccessible to children. Ms. Godwin and Ms. Williams are reminded that any changes to the facility must be reported to and approved by Community Care Licensing. See 809-C for continuation...

SUPERVISOR'S NAME: Monica Cuddy	TELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Samantha Clenista	TELEPHONE: (619) 818-6740
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: YMCA TEENS IN MOTION: RANCHO BERNARDO HIGH	FACILITY NUMBER: 376105068
	VISIT DATE: 08/18/2021

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

This facility plans to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A Plan of Operation that includes IMS must be submitted to the Department. 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.

Ms. Godwin and Ms. Williams states they understands that all staff must have a criminal record clearance and be associated to the adminstrative site prior to having a presence in the Center. Child Care Providers can now sign up for Quarterly Updates and PINS through the DSS website. Please go to www.ccld.ca.gov and click on “Receive Important Updates,” then enter your email address and choose which program you would like to subscribe to and click subscribe. LPA also shared and reviewed Playground Safety Handbook, Risk in Play article, Helping Young Children Cope with Disaster, Active Supervision Handout, and COVID-19 Early Care and Education handout.

No corrections are needed at this site. A license for 30 children (ages 12-18 years old) in Room E14 is granted and effective today's date, 08/18/2021. Facility may take care of individuals up to 22-years-old with an approved exception by the department.

SUPERVISOR'S NAME: Monica Cuddy	TELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Samantha Clenista	TELEPHONE: (619) 818-6740
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2