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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426214475
Report Date: 03/11/2022
Date Signed: 03/11/2022 05:27:45 PM


Document Has Been Signed on 03/11/2022 05:27 PM - It Cannot Be Edited

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:LOMPOC YMCA-MIGUELITO SCHOOL SITEFACILITY NUMBER:
426214475
ADMINISTRATOR:STEPHANIE SAUCEDOFACILITY TYPE:
840
ADDRESS:1600 WEST OLIVE AVENUETELEPHONE:
(805) 757-5038
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:50CENSUS: 15DATE:
03/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:46 PM
MET WITH:Stephanie SaucedoTIME COMPLETED:
05:45 PM
NARRATIVE
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On March 11, 2022 at 2:46 PM, Licensing Program Analysts (LPAs) Francisco Pedroza and Rosie Breault conducted an unannounced Case Management - incident inspection. LPAs met with Director Stephanie Saucedo and advised her the purpose of the inspection. Director provided LPAs a tour of the facility inside and out. There was 15 children in care at the time of the inspection.

On February 23, 2022, Community Care Licensing was informed of an incident that occurred on February 16, 2022. According to the incident report, at around 3:00 PM C1 and C2 were seated at the table having their afternoon snack. While eating their snacks, C3 observed C1 and C2 were touching each other inappropriately. C3 informed staff of the incident. The staff investigated and had the children separate from one another.

On March 11, 2022, LPAs were following-up on the incident and conducting interviews with staff. During the interviews, LPAs were informed about another incident that occurred on February 17, 2022 where the children were outside playing on the playground. During the incident C5 was observed by C1, C2, and C4, pulling his pants down and exposing them self. C1 then touched them self inappropriately on the school handball wall.

During both incidents staff did not observe either incident occur, it was not until the children brought it to staff attention that the children were separated for the first incident on 2/16/2022. Staff failed to implement proper supervision as another incident involving the same children occurred again on 2/17/2022. Staff interviews confirmed that the staff were not positioned in areas where they can physically observe the children when the incidents occurred in the outdoor recreation yard.

Any unusual incident that threatens the physical or emotional health or safety of any child shall be reported by telephone or fax within the Department's next working day and during its normal business hours.

Continued on 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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


Document Has Been Signed on 03/11/2022 05:27 PM - It Cannot Be Edited

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: LOMPOC YMCA-MIGUELITO SCHOOL SITE
FACILITY NUMBER: 426214475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/18/2022
Section Cited

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101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidence by:
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During staff interviews and record reviews it was identified that children inappropriately touched one another and exposed themselves while in care. This poses an immediate Health and Safety risk to clients / children in care.
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Director advised that an office conference will be scheduled at a later date.

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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: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 03/11/2022 05:27 PM - It Cannot Be Edited

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: LOMPOC YMCA-MIGUELITO SCHOOL SITE
FACILITY NUMBER: 426214475

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/18/2022
Section Cited

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101229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision ... to meet the children's needs.
(1) No child(ren) shall be left without the ... Supervision shall include visual observation.
This requirement is not met as evidence by:
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During staff interviews and record reviews it was identified that children inappropriately touched one another and exposed themselves while in care. This poses a potential Health and Safety risk to clients / children in care.
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Director advised that an office conference will be scheduled at a later date.
Type B
03/18/2022
Section Cited

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101212 Reporting Requirements
(d) Upon the occurrence, ... below shall be submitted to the Department within seven days following the occurrence of such event.
(1) Events reported shall include the following:
(C) Any unusual incident ... the physical or emotional health or safety of any child.
This requirement is not met as evidence by:
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During staff interviews and record reviews it was identified that the facility failed to report the second incident that occurred on February 17, 2022 to CCL. This poses a potential Health and Safety risk to clients / children in care.
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Director advised that an office conference will be scheduled at a later date.
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 MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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: LOMPOC YMCA-MIGUELITO SCHOOL SITE
FACILITY NUMBER: 426214475
VISIT DATE: 03/11/2022
NARRATIVE
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In addition, a written report containing the information of the incident shall be submitted to the Department within seven days following the occurrence of such event. Although the legal guardians of the children involved in the incident were informed, staff failed to report the incidents to Community Care Licensing within the required time frame. LPAs spoke with Director about the incidents. LPAs advised Director that the facility will be cited for Personal Rights, Care and Supervision, and Reporting Requirements. Resources regarding the regulations were provided to Director. Director advised that they understood. Director was provided appeal rights.

The facility was cited with deficiencies during today's inspection.

Exit interview conducted and report was reviewed with the Director.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4