561708146-10-10-2019-17-CC-FPEA-BGTUB7-20191010152552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 561708146
Report Date: 10/10/2019
Date Signed: 10/10/2019 03:25:59 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME:	SIMI VALLEY FAMILY YMCA - WHITE OAK		FACILITY NUMBER:	561708146
ADMINISTRATOR:	RYAN FOWLER		FACILITY TYPE:	840
ADDRESS:	2201 ALSCOT AVE.		TELEPHONE:	(805) 527-6915
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	60	CENSUS: 42	DATE:	10/10/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:01 PM
MET WITH:	Valerie Ross		TIME COMPLETED:	03:40 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) Frank Pedroza made an unannounced visit for the purpose of conducting a Case Management - Incident inspection. LPA met with facility Site Supervisor Valerie Ross and discussed the purpose of the visit. LPA and licensee conducted a tour of the facility inside and out. On 10/02/2019, licensee contacted Community Care Licensing (CCL) to self report an incident that occurred at the facility. On 9/30/2019 at/or around 11:00 AM, the facility had an incident with a C1's father who attempted to pick him up early. C1's father was not on the list to be allowed to pick his son up. Facility staff contacted C1's mother and advised her that his father was there to pick him up. C1's mother provided documentation via email that C1's father is able to pick him up. But not until 3:00 PM which is stated on the custody court order. According to staff, C1's father became upset was still going to take him home with him. At one point C1's father started to leave with his son when S1 blocked the door way between C1 and his father preventing him from leaving the facility. Facility staff had called local law enforcement (LE) since C1's father was becoming argumentative and disrespectful towards staff. During the incident staff had the other children outside away from the area redirecting as much as possible. Continued on 809C

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2019

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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: SIMI VALLEY FAMILY YMCA - WHITE OAK	FACILITY NUMBER: 561708146
	VISIT DATE: 10/10/2019

NARRATIVE

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LE arrived and informed C1's father that he cannot take his son with him. C1's father left the facility and returned at or around 3:00 PM which was his court ordered time to pick him up.

The following day C1's father contacted YMCA head quarters to file a complaint against the facility. During that time he stated that C1 was elbowed by staff during the incident. LPA questioned S1 if at any point did she recall C1 being hit. S1 denied striking C1 during the incident. Since the incident C1 has returned back to the facility. He comes to the facility when he is scheduled to be with his mother according to the court order.

Given the licensee's account of the incident when reporting it to CCL and how they addressed the incident, LPA deemed licensee's action was appropriate.

No deficiencies were cited during today's visit.

THE NOTICE OF SITE VISIT WAS POSTED AS REQUIRED BY H&S CODE SEC. 1596.817. THE NOTICE OF SITE VISIT MUST REMAIN POSTED FOR 30 DAYS OR A CIVIL PENALTY OF $100.00 WILL APPLY.

SUPERVISOR'S NAME: George Mingle	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco Pedroza	TELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2019

LIC809 (FAS) - (06/04)

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