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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561710630
Report Date: 12/10/2019
Date Signed: 12/10/2019 02:45:48 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 - SANTA SUSANAFACILITY NUMBER:
561710630
ADMINISTRATOR:TOMAS CACERESFACILITY TYPE:
840
ADDRESS:4300 APRICOT ROADTELEPHONE:
(805) 527-9451
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:60CENSUS: 5DATE:
12/10/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jennifer GuarinoTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Francisco Pedroza conducted an unannounced Annual/Random inspection. LPA met with Child Program Director Jennifer Guarino and Site Supervisor Alexis Sadicario. LPA explained the nature of the inspection and together conducted a tour of the facility inside and out. The center operates from 1:45 PM to 6:30 PM, Monday - Friday. The facility is located on an Elementary school site.

The facility uses the school site restrooms for the children. They have separate restrooms for boys and girls available. During children arrival the facility receives transported children from other school sites. Children that transition from school class to the facility come directly to the classroom. Younger children in the school kindergarten classroom are picked up by staff and escorted to the facility. LPA did not observe any toxins/hazardous items accessible to children. LPA reviewed the posted snack menu. Kitchen, food preparation, 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 for outdoor play. Children have access to age appropriate toys and equipment. Continued on 809-C
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2019
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 - SANTA SUSANA
FACILITY NUMBER: 561710630
VISIT DATE: 12/10/2019
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The facility does not provide incidental medical services (IMS) to children in care. There is drinking water available both inside and outside for the children.

A sampling of children and staff records were reviewed. Teachers have required qualifications. Teachers present have current First Aid/CPR certificates that expire on 03/31/20. LPA verified SB 792 Child Care Adult Immunization and Tuberculosis Requirements. AB 1207 Mandated Reporter Training certificates current that expire on 08/14/20. Site Supervisor was provided a guide for effects of Lead Exposure brochure.

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: 12/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2019
LIC809 (FAS) - (06/04)
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