421702975-12-20-2021-17-CC-GRES-C9VUHA-20211220143536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 421702975
Report Date: 12/20/2021
Date Signed: 12/20/2021 02:35:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	SANTA MARIA VALLEY YMCA		FACILITY NUMBER:	421702975
ADMINISTRATOR:	KELSEY APKARIAN		FACILITY TYPE:	850
ADDRESS:	3400 SKYWAY DRIVE		TELEPHONE:	(805) 937-8521
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY:	44	CENSUS: 14	DATE:	12/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Diana Borjas		TIME COMPLETED:	02:25 PM

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	On December 20, 2021, Licensing Program Analysts (LPAs) Gigi Reyes met with facility Site Supervisor and explained the purpose of the inspection. Prior to inspection, LPA asked pre health screening questions related to COVID 19, Staff responses indicate there were no exposures on site. LPA toured the facility inside and out together with the Director. There were 14 children and 3 staff present during the inspection. LPA observed the following: Licensing required forms were posted prominently at the entrance door of the classroom. The facility is using one classroom for child care. There are two restrooms with enough toilets and sinks readily accessible for children in care. The classroom has age appropriate games, activities, and furniture available. LPA observed and reviewed the posted snack menu. The center provides two snacks daily to children in care. The outdoor playground is completely fenced, as has age appropriate toys and equipment. The playground has an adequate amount of shade available. The center has drinking water fountain available for children outside and water bottle inside the classroom. Center uses written sign-in/out logs at the entrance of the classroom. . A sampling of children and staff records were reviewed. Teachers have required qualifications. Teachers present have current Pediatric First Aid/CPR certificates that expire on 03/13/2022. Teacher present have current AB 1207 Mandated Reporter Training certificates that expires on 11/24/2022. LPA verified SB 792 Child Care Adult Immunization and Tuberculosis Requirements. Facility is following current Covid-19 guidelines. LPA observed that Center does not document the immunization of Children # 1 to 10 on CDPH 286. Child # 3 and Child # 5 do not have consent for emergency medical treatment on file (LIC 627). Child # 3 does not have a copy of Personal Rights form ( LIC 613A ) on file. During today's inspection, deficiencies cited under Title 22 Division 12 of California Code of Regulation.

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: SANTA MARIA VALLEY YMCA	FACILITY NUMBER: 421702975
	VISIT DATE: 12/20/2021

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
26
27
28
29
30
31
32

Center does not provide Incidental Medical Services (IMS). IMS policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A notice of site visit was given and must remain posted for 30 days. Licensee’s signature on this form acknowledges receipt of these rights. Web site address to obtain forms, review quarterly updates, review Title 22 & Health & Safety Codes is: https://www.cdss.ca.gov/inforesources/child-care-licensing

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: SANTA MARIA VALLEY YMCA	FACILITY NUMBER: 421702975
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101220.1(g)

Immunizations

(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the director did not comply with the section cited above. Immunization of 10 day care children Children # 1 to 10 are not documented on CDPH 286 which poses/posed a potential health, safety risk to persons in care.
	POC Due Date: 12/30/2021
	Plan of Correction
1 2 3 4	Director agreed to document immunization submit proof of correction no later than 12/30/2021

Type B

Section Cited

CCR

101220.1(g)(1)

Immunizations

(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled. (1) This requirement includes updating each child's immunization record when the child is due to receive required immunizations after enrollment in the child care center. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the Director did not comply with the section cited above. Immunization of children # 1 to 10 are not documented hence, center cannot track or monitor when is the child due for the next imunization in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2021
	Plan of Correction
1 2 3 4	Deirector agreed to submit a written plan of correction to ensure that children's immunization are documented.

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: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: SANTA MARIA VALLEY YMCA	FACILITY NUMBER: 421702975
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101221(b)(8)(C)

Child's Records

(C) A signed consent form for emergency medical treatment unless the child's authorized representative has signed the statement specified in Section 101220(f). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in Child # 3 and Child # 5 have no consent for medical treatment on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2021
	Plan of Correction
1 2 3 4	Director agreed to obtain a signed LIC LIC 627 or consent for medicatl treatment no later than 12/30/2021 and submit a written plan of correction to CCLD.

Type B

Section Cited

CCR

101223(b)(1)

Personal Rights

(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the director did not comply with the section cited above Child # 3 has no Personal Rights LIC 613A form on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2021
	Plan of Correction
1 2 3 4	Licensee agreed to submit a proof of correction to CCLD no later thatn 12/30/2021

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: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi Reyes	TELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

LIC809 (FAS) - (06/04)

Page: 4 of 4