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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701340
Report Date: 08/22/2019
Date Signed: 08/22/2019 02:28:04 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:MCKINNEY FAMILY YMCA LA JOLLA PRESCHOOLFACILITY NUMBER:
376701340
ADMINISTRATOR:BRENDA STEVENSFACILITY TYPE:
850
ADDRESS:8355 CLIFFRIDGE AVENUETELEPHONE:
(858) 453-3483
CITY:LA JOLLASTATE: CAZIP CODE:
92037
CAPACITY:96CENSUS: 0DATE:
08/22/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Brenda StevensTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analysts (LPA) Samantha Salunga and Chanell Farnese visited the facility to conduct a case management site inspection. Upon arrival, LPAs met with Director, Brenda Stevens, and proceeded to tour the facility. There are no children present due to the facility being closed from 08/21/19-08/23/19 for in-service training. Facility failed to report an unusual incident to Community Care Licensing (CCL) where facility failed to report that on 08/15/19, Child #1 was given pepperoni. Child #1’s parent notified facility that Child #1 is allergic to pork upon enrollment.

See 809D for cited deficiency. NOTICE OF SITE VISIT IS TO BE POSTED FOR 30 DAYS. LPAs observed Director notice of site visit. A printed copy of this report as well as a printed copy of the appeal rights was provided and reviewed with Director at the conclusion of the visit.
SUPERVISOR'S NAME: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Samantha SalungaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2019
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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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: MCKINNEY FAMILY YMCA LA JOLLA PRESCHOOL
FACILITY NUMBER: 376701340
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2019
Section Cited

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Reporting Requirements. Any unusual incident or child absence that threatens the physical or emotional health or safety of any child shall be reported to the Department by telephone or fax within the Department’s next working day and during its normal business hours.
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This was not met as evidenced; facility failed to report that on 08/15/19, Child #1 was given pepperoni. Child #1’s parent notified facility that Child #1 is allergic to pork upon enrollment. This poses a Potential Health and Safety risk to the clients in care.
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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: Monica CuddyTELEPHONE: (619) 767-2249
LICENSING EVALUATOR NAME: Samantha SalungaTELEPHONE: (619) 767-2209
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2019
LIC809 (FAS) - (06/04)
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