384000293-11-18-2019-05-CC-MROZ-BJ2QER-20191118110646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384000293
Report Date: 11/18/2019
Date Signed: 11/18/2019 11:06:56 AM

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., STONESTOWN BRANCH, ST. FRANCIS		FACILITY NUMBER:	384000293
ADMINISTRATOR:	AMANDA LEE		FACILITY TYPE:	850
ADDRESS:	399 SAN FERNANDO WAY		TELEPHONE:	(415) 452-9622
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94127
CAPACITY:	34	CENSUS: 31	DATE:	11/18/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jenny Lam		TIME COMPLETED:	11:30 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	Licensing Program Analyst (LPA) Marie Rodriguez conducted an unannounced Annual Random inspection. LPA met with Site Director Jenny Lam and explained purpose of inspection. The center is located on the lower level of St. Francis Episcopal Church. Present at facility were the Site Director, 4 teachers, 1 teacher's assistant, and 31 children (preschool age). Center is operating within capacity limits and in compliance with staff to child ratio. Hours of operation are Monday to Friday from 7:00am to 6:00pm. LPA toured and inspected center with Director. There are no bodies of water, firearms, or weapons on the premises. There are two classrooms in the center which are in good condition with proper temperature and ventilation and are free of any hazards. Furniture in classrooms are in good repair. Classrooms have age appropriate toys and equipment. There are two bathrooms in center. First bathroom located inside the Koala Classroom has two toilets and one sink. Second bathroom outside of Panda Classroom has two toilets and two sinks. Bathrooms appear to be clean, in good repair, and free of any hazards. There is a separate bathroom for staff usage on the premises. The outdoor play area is fenced for supervision with age appropriate toys and equipment in good condition and with sufficient cushioning underneath. All required postings and waivers are posted on the bulletin board by the entrance of the center. Center provides catered snacks and lunch. A menu is posted for the month. Drinking water is available for children indoor and outdoors. Food prep area is clean and free of any toxins or contamination. All storage containers for solid waste have a proper lid. All cleaning products, chemicals, and toxins are inaccessible to children. Napping equipment are properly stored when not in use. Bedding for cots are stored in children's cubbies when not in use and are brought home at the end of each week for cleaning. Last emergency drill was conducted on October 17 2019. Emergency drills are conducted monthly and are properly logged. The center has a complete record of sign-in/out sheets by authorized pickup person electronically. There is a working fire alarm system, three fully charged fire extinguishers, a smoke and carbon monoxide detector, and a working telephone available on site. (Continued on second page)

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2019

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: YMCA OF SF., STONESTOWN BRANCH, ST. FRANCIS	FACILITY NUMBER: 384000293
	VISIT DATE: 11/18/2019

NARRATIVE

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(Continued from first page)

Six children records reviewed were complete. All children have a record of emergency identification information on file. Five staff records reviewed were complete. All staff have a criminal record clearance on file. Staff have current Pediatric First Aid/CPR certificates on file which expire on either December 2019 or July 2020. Incidental Medical Services (IMS) was discussed with Director. There is an IMS plan in place with no children receiving services during the 2019-2020 school year.

During inspection,

Director was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.662.
Director was reminded about Mandated Reporter Training. Training must be completed by staff every two years. (Website: www.mandatedreporterca.com).
Director was reminded about the Provider Information Notices (PINs) on CCLD website.

No deficiencies cited today.

This report was reviewed and discussed with Director Jenny Lam. A copy of report was provided.
Notice of site visit was observed being posted and shall remain posted for 30 days.

For any additional questions, call San Bruno CCLD Office, Monday - Friday, 8am - 5pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

The following forms are to be updated and submitted to CCLD by December 2, 2019:
LIC 500 – Personnel Report
LIC 610 - Emergency Disaster Plan

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2019

LIC809 (FAS) - (06/04)

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