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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709472
Report Date: 05/11/2022
Date Signed: 05/11/2022 04:23:05 PM


Document Has Been Signed on 05/11/2022 04:23 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:YMCA-BOOKSINFACILITY NUMBER:
430709472
ADMINISTRATOR:TONI BROWNFACILITY TYPE:
840
ADDRESS:1590 DRY CREEK ROADTELEPHONE:
(408) 265-3588
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:140CENSUS: 15DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Deborah PaselkTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Ofelia Calivo met with Director Deborah Paselk for an unannounced Required 1-year inspection. Facility's License, Notification of Parents’ Right Poster, Child Car Seat Law, Personal Rights (LIC 613A), Emergency Disaster Plan, and Earthquake Preparedness Checklist were observed to be posted. Days and hours of operation are Monday - Friday from 2:00 P.M - 6:00 P.M. The facility is licensed to serve from kindergarten to 12 years old. Due to low enrollment, only classroom G is being used by the children.

LPA toured the facility both indoor and outdoor. LPA observed that the facility was operating in compliance with teacher to children ratio requirement. Furniture and equipment were observed to be age appropriate and in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, and other items that are dangerous to children were stored inaccessible to children. Floors were clean.

Foods and beverages were kept protected against contamination and spoilage. Drinking water is available for the children indoor via individual water bottles. Trash cans for solid waste had tight-fitting covers on and were in good repair. Fire extinguisher, working smoke and carbon monoxide detectors were observed.
Deborah stated that there are no firearms in the facility. Drinking water is readily available for the children outdoor via water bottles. The school age program uses Booksin Elementary School playground after school hours. LPA observed proper amount of cushioning under the play area by poured rubber matting. There were no bodies of water observed.

LPA reviewed 12 children's files. Children records reviewed include Admission Agreement, Identification and Emergency Contact, Consent for Emergency Medical Treatment form, receipt of Parent Rights Notice, Personal Rights Notice, and Pre-Admission Health History.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Ofelia CalivoTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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-BOOKSIN
FACILITY NUMBER: 430709472
VISIT DATE: 05/11/2022
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Three staff file were reviewed. Staff records reviewed include Criminal Record Statement, Personnel Record, Employee Rights, Health Screening Report with TB Clearance, Immunization (Measles, Pertussis, and Flu) record and required Training. LPA reminded Deborah that the online AB1207 Mandated Reported Training needs to be renewed every two years. At least one staff member present during the inspection has current certification in Pediatric CPR and First Aid.

This facility provides Incidental Medical Services – IMS. Deborah stated that currently, there are no children using medication. 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

Deborah 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.

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.

As a result of this inspection, there were no deficiencies cited.

Exit interview conducted and report was reviewed with the Site Supervisor, Deborah Paselk.

A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Ofelia CalivoTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC809 (FAS) - (06/04)
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