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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380503900
Report Date: 05/21/2019
Date Signed: 05/21/2019 01:04:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:YMCA OF SF., MISSION BRANCH, MISSION PRESCHOOLFACILITY NUMBER:
380503900
ADMINISTRATOR:ALVAREZ, KATIAFACILITY TYPE:
850
ADDRESS:4080 MISSION STREETTELEPHONE:
(415) 586-6900
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:42CENSUS: 39DATE:
05/21/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Katia AlvarezTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst, LPA Yee conducted a case management inspection today. There are 39 children and 7 staff members at the facility. The incident occurred on 5/3/2019 was not reported to the licensing department. The reporting requirement was discussed today.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: YMCA OF SF., MISSION BRANCH, MISSION PRESCHOOL
FACILITY NUMBER: 380503900
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2019
Section Cited
CCR
101212(d)(1)(C)
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101212(d)(1)(C): Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours.
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LPA obtained incident report during the inspection.

Deficiency has been corrected.
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On 5/3 staff observed two children inappropriate behaviors and the facility failed to report this incident to CCL.

This requirement was not met as evidence-based upon interviews. This poses a potential health risk to children 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: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2