430709586-12-8-2022-07-CC-KMEO-CLWVQR-20221208153845

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430709586
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:38:50 PM

Document Has Been Signed on 12/08/2022 03:38 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	YMCA-HACIENDA VALLEY VIEW		FACILITY NUMBER:	430709586
ADMINISTRATOR:	SARAH MILLER		FACILITY TYPE:	840
ADDRESS:	1290 KIMBERLY DRIVE		TELEPHONE:	(408) 978-1156
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	105	CENSUS: 42	DATE:	12/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:48 PM
MET WITH:	Roy Que- Heath and Audrey Voss		TIME 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	On December 8th, 2022 at 1:50pm , Licensing Program Analyst (LPA) Kassandra Medrano conducted a random annual licensing inspection today. LPA met with Roy, Director, and Audrey Voss, Youth development program director, the purpose of the visit was explained. The facility is located on functioning public school site, Hacienda Elementary School. LPA inspected the facility building and grounds, conducted an evaluation of the physical plant, and reviewed children, staff and facility records. A review of staff records during today’s visit indicates that all staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Facility representative was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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. The program operates Monday-Friday, 7am-9am and afternoon session 3pm-6pm. The following was observed today:Current facility director is Roy Que Heath. Current rooms used for care Portable which are listed as rooms 38 and 39. The following items were reviewed as part of today's visit: Care and Supervision of the Children, Child Discipline Procedures, Emergency Evacuation Procedures (smoke and carbon monoxide detectors present and in working order), Medication Policies, Isolation of Sick Children, Food Service, Transportation, Parents Rights, and Reporting Requirements. Bathrooms for school age children are located within in the classrooms. The outdoor play area is located right out front of the portables. Supervision of school age children using a functioning school site public playground is achieved by direct supervision. Children are signed in to the facility by staff and out of the facility by parents, all sign in and sign out sheets are all digital. Posting requirements for site visits were discussed as well as AB 633 requirements. Current forms and Title 22 Regulations can be obtained through the internet at www.ccld.ca.gov. Staff immunization are on file. Director was reminded that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. Influenza Declarations were also reviewed.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

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

FACILITY NAME: YMCA-HACIENDA VALLEY VIEW	FACILITY NUMBER: 430709586
	VISIT DATE: 12/08/2022

NARRATIVE

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LPA reviewed with facility representative the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted. Director was advised of the required annual pesticides training. For More information about changes to the Healthy Schools Act, templates, or articles, you can inspect the DPR website at:
https://apps.cdpr.ca.gov/schoolipm/childcare/training/main.cfm. Director was informed about the Provider Information Notices (PINs) on CCLD website. Director was reminded of Mandated Reporter Training available on CCLD website. Training must be renewed every two years.This facility provides IMS. A review of storage of medications, equipment and supplies, and reviewed children, personnel and administrative records. Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

The following items need to be completed and returned to Licensing by 01/08/22:
-PERSONNEL REPORT (LIC 500)
-EMERGENCY DISASTER PLAN (LIC 610)
-NEW DIRECTOR INFORMATION: DESIGNATION OF ADMIN RESP (LIC 308), PERSONNEL RECORD (LIC 501), HEALTH SCREENING REPORT (LIC 503), IMMUNIZATION RECORD FOR MEASLES, PERTUSSIS AND INFLUENZA DECLARATION, LETTERS OF EXPERIENCE FROM PREVIOUS EMPLOYERS, TRANSCRIPTS/DEGREE/VALID CHILD DEVELOPMENT PERMIT,MANDATED REPORTER, SIGNED STATEMENT ACKNOWLEDGING REQUIREMENT TO REPORT SUSPECTED CHILD ABUSE, SIGNED NOTICE OF EMPLOYEE RIGHTS AND CRIMINAL RECORD STATEMENT,PROOF OF COMPLETION OF 16 HOURS PREVENTATIVE HEALTH PRACTICES, INCLUDING CPR AND FIRST AID.

Exit interview conducted and report was reviewed with the facility representative, Roy.
"NOTICE OF SITE VISIT" DOCUMENT WAS POSTED ADJACENT TO THE MAIN ENTRY DOORWAY AND VISIBLE TO PARENTS AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kassandra Medrano	TELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC809 (FAS) - (06/04)

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