430709472-2-5-2025-07-CC-JBER-DDLVWE-20250205154748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430709472
Report Date: 02/05/2025
Date Signed: 02/05/2025 03:47:58 PM

Document Has Been Signed on 02/05/2025 03:47 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	YMCA-BOOKSIN		FACILITY NUMBER:	430709472
ADMINISTRATOR/ DIRECTOR:	DEBORAH PASELK		FACILITY TYPE:	840
ADDRESS:	1590 DRY CREEK ROAD		TELEPHONE:	(408) 265-3588
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY: 35	TOTAL ENROLLED CHILDREN: 35	CENSUS: 31	DATE:	02/05/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Audrey Voss, Program Director & Deborah Paselk, Acting Director		TIME VISIT/ INSPECTION COMPLETED:	04:00 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	Licensing Program Analyst (LPA), Jennifer “Jen” Beehler, met with Program Director, Audrey Voss and Acting Director Deborah Paselk, for an Annual/Random inspection. LPA was granted access to the facility by the Program Director and toured both indoors and outdoors during the inspection. Upon arrival, there were 31 children (school-age) and 3 staff (2 Directors / 1 Assistant) present, which is compliant with the facility license capacity and ratio requirements. LPA observed all required postings near the entrance to the facility. Hours of operation for the facility are Monday – Friday, 06:45AM-08:15AM and 01:45PM - 6:00PM. The facility has an active waiver to associate all criminal record clearance on the YMCA-Eisenhower License #430709334. Program Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. All staff present had criminal record clearance and were associated to the roster on Guardian. LPA reviewed sign-in/out sheets, facility roster (LIC9040), and fire/disaster drill log during today’s inspection. Sign-in/out was observed to be completed with full legal signature and time of day. The last fire/disaster drill was conducted on 01/15/2025, which is compliant with the six month requirement for facilities. LPA observed a fully charged 3A40BC fire extinguisher last serviced 01/02/2025, which is compliant with state fire marshal regulations. LPA observed a fully functioning smoke detector system and a working carbon monoxide detector. Director states that she does have children in care who require Incidental Medical Services. Continued on Page 2

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

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

FACILITY NAME: YMCA-BOOKSIN	FACILITY NUMBER: 430709472
	VISIT DATE: 02/05/2025

NARRATIVE

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LPA observed Director Paselk administering medication to a child in care and met all the directives in writing. This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. All medications were kept in a locked and in separate bags with instructions from parents in their original packaging with the manufacturer's instructions. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Indoor areas of the facility were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via water dispensers and disposable cups in addition to water bottles from home labeled with the children’s names. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom, not utilized by the children. The facility has a site phone for the program. Cleaning and maintenance for the facility is conducted by an outside service and is completed in the evenings after all day care children have left the premises. The Program Director states that there are no weapons or firearms on the premises.

The outdoor area of the facility was inspected and observed to be fenced in. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials (firm foam) to absorb falls. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by trees and building overhang.

Food is provided by the facility and is stored, prepared, and served in a safe and healthful manner to the children. Facility offers an afternoon snack to children. Menu is in writing and posted at least one week in advance, accessible to authorized representatives. The kitchen and storage area is clean and free of litter and rubbish. Equipment necessary for the storage, preparation and service of food is well maintained, clean, and sanitized after each use.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

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

FACILITY NAME: YMCA-BOOKSIN	FACILITY NUMBER: 430709472
	VISIT DATE: 02/05/2025

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5 children’s files (school-age) were reviewed during today’s inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), LIC701 Health History/Parent's Report, Signed Admission Agreement, Personal Rights (LIC613A). LPA observed all files to be complete.

3 staff files (2 directors / 1 aide) were reviewed for the following records: Transcripts/Verification of Experience, Health Screening Report (LIC503), Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, Tuberculosis (TB) Clearance, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza). There is at least one staff member present with current CPR/First-Aid that expires 06/21/2025. The Director has current Mandated Reporter Training that expires on 05/21/2026. LPA reminded Program Director that the Mandated Reporter Training must be renewed by all staff every 2 years and meet the requirement of AB1207.

The Program Director understands that the site director shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times. LPA reminded Director that there shall be at least one person with valid CPR and First-Aid certifications on site at all times or present during off site activities, such as field trips.

LPA provided a copy of the most recent application to the Program Director and advised that it needs to be liquid signed with no corrections or cross outs. This will correct the mailing address and change the Director.

The following Documents were collected during today's inspection:

Lead Test Dated 02/07/2023 showing all facilities passed

Exit interview conducted with Program Director Audrey Voss, report reviewed and provided. NOTICE OF SITE VISIT PROVIDED AND MUST REMAIN POSTED FOR 30 DAYS.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

LIC809 (FAS) - (06/04)

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