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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573601607
Report Date: 08/28/2019
Date Signed: 08/28/2019 10:44:58 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:YMCA OF THE EAST BAY-WOODLANDFACILITY NUMBER:
573601607
ADMINISTRATOR:ROBLES, SOCORROFACILITY TYPE:
850
ADDRESS:1285 LEMEN AVETELEPHONE:
(530) 668-9622
CITY:WOODLANDSTATE: CAZIP CODE:
95776
CAPACITY:75CENSUS: 60DATE:
08/28/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sandra Torres-Hernandez and Socorro RoblesTIME COMPLETED:
10:55 AM
NARRATIVE
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During the course of the complaint investigation Licensing Program Analysts Chayntel Hunter and Charlotte Baney learned that three staff members were fingerprint cleared but not associated to the facility.

Deficiencies cited on subsequent 809-D page.

Appeal rights were given. An exit interview was conducted. Notice of Site Visit was provided and posted.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: YMCA OF THE EAST BAY-WOODLAND
FACILITY NUMBER: 573601607
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2019
Section Cited

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All individuals subject to a criminal record review shall, prior to working, residing or volunteering in a licensed facility:
Request a transfer of a criminal record clearance.
This requirement was not met as evidenced by:
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LPAs observed three staff members that had fingerprint clearances but were not associated to the facility, and had not completed a clearance transfer request.
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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: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2