430703921-12-3-2019-07-CC-AALZ-BJJ2J6-20191203162549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430703921
Report Date: 12/03/2019
Date Signed: 12/03/2019 04:25:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	YMCA-SIMONDS		FACILITY NUMBER:	430703921
ADMINISTRATOR:	BRIAN WESTFALL		FACILITY TYPE:	840
ADDRESS:	6515 GRAPEVINE WAY		TELEPHONE:	(408) 268-7125
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95120
CAPACITY:	70	CENSUS: 40	DATE:	12/03/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Ogle, Kristina		TIME COMPLETED:	04:25 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	An unannounced Annual Random Inspection was conducted on this day by Licensing Program Analyst (LPA) Almaraz, Araceli. Facility is currently licensed for a capacity of 70. Licensing staff met with Site supervisor Ogle, Kristina . This program currently operates 6:45 AM to 9:00 AM for (for morning children) Monday thru Friday. This school age program currently operates Monday, Wednesdays, Thursdays and Fridays from 2:30 PM to 6:00 PM for afternoon children. On Tuesdays the afternoon program is from 1:30 PM to 6:00PM, the morning schedule is the same. Licensing staff was taken on a guided tour of the facility of both indoors and outdoors. Physical Plant: This facility consists of two adjoining portables. All areas on the facility sketch were identified and inspected by licensing staff. At the initial start of the site visit, there is a total census of 40 school age children. There were two teachers present and two aides. The following was observed by LPA Almaraz: Portable 1: Upon arrival room had one teacher, one aide and 19 school aged children present. Access to one facet, two sinks, one toilet and drinking water located inside classroom. Teacher and child ratios were observed and staff names recorded. Children in this room are from kinder through second grade. Portable 2: Upon arrival room had one teacher, one aide and 21 school aged children present. Access to one facet, two sinks, one toilet and drinking water located inside classroom. Teacher and child ratios were observed and staff names recorded. Chilren in this room are from second grade through fifth grade. Furniture and equipment were inspected for age appropriateness and are in sufficient condition. Telephone service, heating, lighting and ventilation were evaluated. Children have their own cubby to store their belongings. Per Ogle, the isolation area is in the office. General sanitation was observed. ***Page 1/3, Report Continued on Page 2***

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: YMCA-SIMONDS	FACILITY NUMBER: 430703921
	VISIT DATE: 12/03/2019

NARRATIVE

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Disinfectants, cleaning solutions, medication and other hazardous items that pose a risk to children, were inaccessible to the children in care. Ogle states that poisons are locked in the staff room closet. All areas are kept clean and are free of litter, rubbish, rodents, and/or any other vermin. All storage containers for solid waste, including moveable trash receptacles have tight-fitting covers that are kept on, and in standard condition. First Aid supplies were observed in the classrooms. According to Ogle, medication is only administered to a child when accompanied with a doctor's note and is locked and stored in the office. Carbon monoxide detectors and smoke detectors are and working present in the facility. There are two Fire extinguishers size 3A40BC, last serviced on 02/02/2019 in each side of portable.

Lavatories: LPA Almaraz observed lavatories that were inspected and are in sufficient condition. LPA observed age appropriate sinks and toilets, water temperature, toilet paper, area safety and sanitation. LPA Almaraz observed soap dispenser and disposable towels. Staff has one separate lavatory on campus that can be utilized by sick children if necessary. Sick children are isolated in the director's area.

Outdoor playground equipment is in a safe condition, free of sharp, defective or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All areas around or under high climbing equipment, swings, slides, and similar equipment are cushioned with material that absorbs a fall. There is adequate shade in the play yard. Availability of outdoor drinking water was observed. Ogle states that although this area is shared with the school district children, supervision and different schedules ensures commingling is age appropriate.

FACILITY RECORDS

Teacher-child ratios were observed and staff names recorded. Care and supervision was evaluated to determine if the basic needs of children are met and appropriate. Sign-in and out sheets and procedures were reviewed. Personal Rights of children were observed by LPA.

Staff and Children’s Records were reviewed. Criminal Record Clearances were reviewed for adults.. Inspection of required forms made. *****Page 2/3, Report Continued on Page 2*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: YMCA-SIMONDS	FACILITY NUMBER: 430703921
	VISIT DATE: 12/03/2019

NARRATIVE

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All individuals present have obtained a criminal record clearance or criminal record exemption. There is at least one person trained in CPR and Pediatric First Aid present during this inspection. (All staff have received an active criminal record clearance as a condition of their employment.) Children’s Records were reviewed for completeness; Inspection of required forms was made. LPA issued the Children’s Record Review (LIC 857) to Ogle during this inspection. In review of children’s records, files contain information including, but not limited to the following: Name, address and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child if the authorized representative cannot be reached when necessary.LPA also issued the Review of Staff records (LIC 859) to Ogle during this inspection. Children's roster was reviewed and is current. Sign-In and Sign-Out sheets were reviewed. Children present were signed in. Disaster drill log was available, last drill was conducted on 11/13/2019..

Menus are posted one month in advance where it is visible by the child's authorized representative. Menus for the past 30 days are available upon request. Snacks were reviewed for availability, quantity and appropriateness to children in care. Chidlren can bring their own food. The facility provides AM and PM snacks..

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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

Ogle was also advised of the requirement to report Unusual Incidents and/or injuries to the parent/guardian and to CCL within the time frame specified by the regulation. Ogle was advised that indoor and outdoor supervision required at all times. If outdoor area not adequately fenced, provider must be with children at all times when outdoors. These forms may also be downloaded from our website: www.ccld.ca.gov

There were no deficiencies cited during today's visit in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1
NOTICE OF SITE VISIT ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS.
*****Page 3/3, Final Page of Report Continued from Page 2*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3