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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376700327
Report Date: 01/30/2020
Date Signed: 01/30/2020 03:02:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:MOTTINO FAMILY YMCA-EMPRESSAFACILITY NUMBER:
376700327
ADMINISTRATOR:MERAZ, ADRIANFACILITY TYPE:
840
ADDRESS:4701 MESA DRIVETELEPHONE:
(760) 758-0808
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY:49CENSUS: 45DATE:
01/30/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tim Stong/ Adrian MerazTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Otsanya Cameron, arrived at the facility toconduct an annual inspection. Facility staff were not on sight due to afterschool program pick-ups. Facility staff arrived back on sight around 2:43pm. LPA was unable to complete an annual inspection on this date, however, a schedule was discussed and will be sent via email to better assist with future annual inspections.
SUPERVISOR'S NAME: Dawn ParkerTELEPHONE: (951) 320-2101
LICENSING EVALUATOR NAME: Otsanya CameronTELEPHONE: (951) 970-1388
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2020
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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