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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009730
Report Date: 08/15/2023
Date Signed: 08/16/2023 10:59:27 AM


Document Has Been Signed on 08/16/2023 10:59 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/16/2023 10:01 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

NARRATIVE
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A required one year inspection was made to the facility by Licensing Program Analyst (LPA), Amy Strother. LPA met with facility representative, Traci Imm (D1). Facility representative 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. During today's visit two staff present S2 and S3 did not have a criminal record clearance associated to the facility. Based on an interview with D1, S2 and S3 are fingerprint cleared through YMCA, but not with Community Care Licensing.

This program is located on the Northwest Prep School Campus and adjacent to YMCA Sunshine Company-Piner Preschool #493002381. This program has a waiver for rotational use of the outdoor activity space to include no more than 7 infants on the playground at one time.

The facility’s operating hours are 7:00am - 6:00pm, Monday – Friday. The facility was toured inside and outside, and the floor and yard plan submitted by the licensee were verified. Sign in/out records were reviewed and in compliance. Items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be inaccessible to children located on high shelves out of reach of children. D1 stated there are no poisons in the facility, and none were observed during this inspection. LPA observed the toys, floors, desks and other equipment and surfaces are clean, toxic free, safe, and in good condition. There is uncontaminated drinking water available to children indoors and outdoors by use of individual water bottles. The infant's diaper changing area was in safe and sanitary condition. The center’s isolation area for any child who becomes ill while in care is located in the staff office area. LPA observed food prep areas are clean. Food is properly stored and refrigerated as needed. There was no contaminated food observed. Garbage cans containing solid waste have tight fitting lids. Menus are posted in the entry of the school on the parent board. There is a working smoke detector, carbon monoxide detector and fire extinguisher in the facility. LPA observed the playground equipment and surface areas were in safe condition.

Continued on LIC809-C

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
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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Document Has Been Signed on 08/15/2023 08:18 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SONOMA COUNTY FAMILY YMCA
FACILITY NUMBER: 493009730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above for two of out of four staff. S2 and S3 were working in the facility without a criminal record clearance with Community Care Licensing which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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D1 stated that the hours of operation will be adjusted from the current 7:00am-6:00pm to 8:00am-4:30pm while S2 and S3 complete the LiveScan fingerprint process and are cleared and associated to the license. D1 stated that the Senior Program director or Program Director will come in to give staff breaks. The facility will submit proof of S2 and S3's LiveScan completion and a written plan for procedures for obtaining criminal record clearances for newly hired staff in the future. Due by 08/16/23 to amy.strother@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/15/2023 08:18 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SONOMA COUNTY FAMILY YMCA
FACILITY NUMBER: 493009730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in one out of three staff files. S2 did not have record of immunity to Measles and Pertussis on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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D1 stated that she will require S2 to submit proof of immunity to Measles and Pertussis and place it in S2's file. D1 will submit proof of immunity to LPA by 09/15/23 at amy.strother@dss.ca.gov
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 3 files. D1, S1 and S2 did not have current Pediatric CPR and first aid certificates on file. D1's last certificate expired on 04/2023 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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D1 stated that she has already signed up for a EMSA approved course scheduled for 09/02/23. D1 will submit proof of class completion with certificate to LPA by 09/15/23. amy.strother@dss.ca.gov
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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/15/2023 08:18 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SONOMA COUNTY FAMILY YMCA
FACILITY NUMBER: 493009730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 3 staff files. S1 and S2 did not have health screening or TB clearances on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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D1 will require S1 and S2 to obtain a health screening, using form LIC503 and obtain a TB clearance (negative test or statement of no risk of TB) by 09/15/23. Submit to amy.strother@dss.ca.gov
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 3 staff files. D1's Mandated Reported Training certificate expired 07/2023 and D1 stated that S2 has never completed the Mandated Reporter Training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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D1 stated that she believes that all staff have completed the mandated reporter training and will obtain certificate to add to staff files and submit proof to LPA by 09/15/23. amy.strother@dss.ca.gov
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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/15/2023 08:18 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SONOMA COUNTY FAMILY YMCA
FACILITY NUMBER: 493009730

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.3(a)
Modifications to Infant Needs and Services Plan
(a) The written infant needs and services plan shall be updated at least quarterly, or as often as necessary to assure its accuracy.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 infant's files. C2-C4 did not have updated needs and service plans. C2's was last updated 02/01/23, C3's was last updated 04/21/23 and C4's was last updated 01/06/23, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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D1 stated she will have C2-C4's Needs and Service plans, signing and dating them. Submitting proof to LPA by 09/15/23. amy.strother@dss.ca.gov
Type B
Section Cited
CCR
101220.1(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled. (1) This requirement includes updating each child's immunization record when the child is due to receive required immunizations after enrollment in the child care center.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 infants files. C2 - C4 did not have current proof of required immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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D1 stated she will request current immunation records from the parents of C2-C4, and verify that C2-C4 have the required immunizations adding them to the CDPH286 form. D1 will submit updated records to LPA by 09/15/23. amy.strother@dss.ca.gov
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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SONOMA COUNTY FAMILY YMCA
FACILITY NUMBER: 493009730
VISIT DATE: 08/15/2023
NARRATIVE
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There is artificial turf underneath climbing structure to absorb falls. There were no bodies of water observed on the site. D1 stated no weapons are stored on site, and none were observed.

During today's inspection, staffing ratios were being met, a total of 5 infants were being supervised by one teacher and one aide. The facility was operating within the licensed capacity and ratio requirements. No staff member present during the inspection possessed current CPR and First Aid certifications, D1’s certificate expired 04/2023.

Five infant’s records (C1-C5) were reviewed and did not contain complete and current information as required. C2-C4 did not have proof of current immunizations. C2-C4 did have needs and service plans on file, but they had not been updated quarterly. C2's needs and service plan was last updated 02/01/23, C3's last updated 04/21/23 and C4's last updated 01/06/23. Three staff files were reviewed and did not contain all records as required. D1 and S2 did not have current Mandated Reporter Training certificates on file. S2 did not have proof of immunity to Measles and Pertussis on file. S1 and S2 did not have a health screening with a TB clearance on file.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Continue on LIC809-C

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SONOMA COUNTY FAMILY YMCA
FACILITY NUMBER: 493009730
VISIT DATE: 08/15/2023
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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/ .

Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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.

A notice of site visit was given to facility representative and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the facility representative, Traci Imm.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided. A Civil Penalty of $200 had been assessed on form LIC421BG.

LPA Strother informed facility representative, Traci Imm that this report dated 08/15/23 documents one Type A citation. Type A citations, shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Strother informed the facility representative to provide a copy of this licensing report dated 08/15/23 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023
LIC809 (FAS) - (06/04)
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