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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566213104
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:35:17 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 - BIG SPRINGSFACILITY NUMBER:
566213104
ADMINISTRATOR:JAMIE GONZALEZFACILITY TYPE:
840
ADDRESS:3401 BIG SPRINGSTELEPHONE:
(805) 368-4815
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:75CENSUS: 0DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Edie CormierTIME COMPLETED:
02:50 PM
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On December 9, 2021 at 1:30 PM, Licensing Program Analysts (LPAs) Francisco Pedroza and Dean Thompson conducted an unannounced Annual/Random inspection. LPAs met with Site Supervisor Edie Cormier and advised her the purpose of the inspection. Site Supervisor provided LPAs a tour of the facility inside and out. There were no children in care at the time of the inspection.

Facility is located on a local elementary school. Licensing required notices were posted prominently on the wall in the classroom. The facility uses two classrooms for children in care. The facility currently uses the elementary school restrooms. Site supervisor advised that children are escorted to the restroom. LPAs observed the classrooms have age appropriate games, activities, and furniture available for children in care. LPAs observed and reviewed the posted snack menu. The center provides one snack daily for children in care. Facility uses the elementary black top for outdoor play. The outdoor playground has age appropriate toys and equipment. The playground has an ample amount of shade available. The center has water available for children inside and out.

Center uses written sign-in/out logs at the entrance of the facility. Facility has all staff and children records stored electronically. A sampling of children and staff records were reviewed. Teachers have required qualifications. Teachers present have current Pediatric First Aid/CPR certificates that expire on 5/1/2023. Teachers present have current AB 1207 Mandated Reporter Training certificates that expire on 3/18/2022. LPAs verified SB 792 Child Care Adult Immunization and Tuberculosis Requirements. Facility is following current Covid-19 guidelines.

No deficiencies were cited during today's visit.

Continued on 809 – C
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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 - BIG SPRINGS
FACILITY NUMBER: 566213104
VISIT DATE: 12/09/2021
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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

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Director was reminded that all adults 18 and over, 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.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Director
SUPERVISOR'S NAME: George MingleTELEPHONE: (805) 562-0411
LICENSING EVALUATOR NAME: Francisco PedrozaTELEPHONE: (805) 689-4212
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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