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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561710629
Report Date: 12/16/2019
Date Signed: 12/16/2019 02:34:33 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 - KATHERINEFACILITY NUMBER:
561710629
ADMINISTRATOR:MEGAN BEAUVOIRFACILITY TYPE:
840
ADDRESS:5455 KATHERINE STREETTELEPHONE:
(805) 527-8581
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:60CENSUS: 0DATE:
12/16/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Tomas CaceresTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Francisco Pedroza conducted an unannounced Annual/Random inspection. LPA met with Site Director Tomas Caceres and advised him the purpose of the inspection. LPA and Director together toured the facility inside and out. There was no children in care at the time of the inspection. The facility operating hours are from 1:45 PM to 6:30 PM, Monday through Friday. The facility is located on an Elementary school site.

Licensing required notices were posted prominently on the wall at the entrance of the facility. The facility uses the school site restrooms for the children. They have separate restrooms for boys and girls available. LPA did not observe any toxins/hazardous items accessible to children. LPA reviewed the posted snack menu. The facility provides one snack for children after school. The food preparation and storage area are kept clean, free of litter. Food is properly labeled and dated in the refrigerator. The facility has carpeted flooring in the classroom. Furniture and equipment were in good condition. The facility uses the school site blacktop playground and grass area for outdoor play. Children have access to the basketball courts and other age appropriate toys and equipment. There is drinking water available both inside and outside for the children. The facility does not provide Incidental Medical Services. Continued on 809C
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2019
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 - KATHERINE
FACILITY NUMBER: 561710629
VISIT DATE: 12/16/2019
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Center uses written sign-in/sign-out sheets. A sampling of children and staff records were reviewed. Teachers have required qualifications. LPAs verified SB 792 Child Care Adult Immunization and Tuberculosis Requirements. Teachers present have current First Aid/CPR certificates that expire on 06/02/21. Teachers AB 1207 Mandated Reporter Training certificates were current and expire on 09/07/21. The facility's last conducted emergency drill was on 12/04/19.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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)/ (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

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 MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2019
LIC809 (FAS) - (06/04)
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