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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414004719
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:20:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/22/2023 and conducted by Evaluator Catrina Quimbo
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20231222085020
FACILITY NAME:YMCA OF SF-PENINSULA BRANCH-PORTOLA ASPFACILITY NUMBER:
414004719
ADMINISTRATOR:SENORES, ANNEFACILITY TYPE:
840
ADDRESS:300 AMADOR AVENUETELEPHONE:
(650) 440-5570
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:75CENSUS: 49DATE:
02/27/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lariece WilliamsTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility is operating out of ratio.
INVESTIGATION FINDINGS:
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On February 27, 2024 at approximately 2:30pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, complaint visit. LPA met with program director, Lariece Williams, and explained the purpose of the visit. Present during visit included 49 children and 5 staff (including director).

During investigation, LPA conducted classroom observations and reviewed facility records. During LPA’s visit conducted 1/17/2024, LPA observed one staff member supervising 21 school age children. Facility was not operating within ratio. Program director stated they have conducted an informal staff meeting, reinforcing the importance of supervision and maintaining ratio.

Based on observation, interview and record review which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 are being cited. Please refer to 9099D for more information.
(Continue Report on 9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 05-CC-20231222085020
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: YMCA OF SF-PENINSULA BRANCH-PORTOLA ASP
FACILITY NUMBER: 414004719
VISIT DATE: 02/27/2024
NARRATIVE
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(Continued, Page 2...)

Facility was cited a type B citation for not operating within ratio. A plan of correction was discussed with program director. Program director stated they will conduct a formal staff meeting with staff. Proof of meeting to be sent to LPA by POC due date.

A notice of site visit was given and must remain posted for 30 days. Appeal rights were also provided during visit.

Exit interview conducted and report was reviewed with program director, Lariece Williams.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 05-CC-20231222085020
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: YMCA OF SF-PENINSULA BRANCH-PORTOLA ASP
FACILITY NUMBER: 414004719
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2024
Section Cited
CCR
101516.5(b)(1)
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101516.5 Teacher-Child Ratio (b)(1) A teacher shall supervise no more than 14 children...
This requirement was not met as evidenced by:
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Program director will conduct a staff meeting discussing the importance of maintaining ratio. Program director will develop a written plan maintaining ratio that all staff will sign. Proof of meeting will be provided to LPA by POC due date.
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Based on observation and interview, one staff member was left with 21 children, operating out of ratio. This poses a potential health, safety or personal rights risks 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.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3