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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573616914
Report Date: 12/05/2019
Date Signed: 12/05/2019 04:10:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:YMCA OF SUPERIOR CALIFORNIA - ZAMORA ELEMENTARYFACILITY NUMBER:
573616914
ADMINISTRATOR:CASTRO, NATALIEFACILITY TYPE:
840
ADDRESS:1716 COTTONWOOD STREETTELEPHONE:
(530) 902-2208
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:64CENSUS: 29DATE:
12/05/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Director, Micah HelmsTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Chayntel Hunter met with Director, Micah Helms for the purpose of an unannounced Annual/Random inspection. LPA observed 29 school aged children supervised by 3 staff. The Director stated school aged children arrive at the facility at 2:45 PM. LPA toured the facility inside and out. LPA observed that hazardous items (disinfectants, cleaning solutions, etc.) were inaccessible to children in care. Facility days and hours of operation are Monday - Friday from 6:45 AM to 8:45 AM and from 2:45 PM to 6:00 PM, or Wednesday from 1:36 PM to 6:00 PM. The program does not operate during the summer. The winter break hours are Monday through Friday 6:45 AM to 6:00 PM. Program provides morning and afternoon snacks and children bring their own lunches during the school year break.

LPA observed the following items during today's inspection: care and supervision of children, staffing ratios, first aid supplies, furniture, equipment, and access to drinking water. LPA observed all required forms to be posted. Outdoor play area was toured.

LPA reviewed the sign in/out book and observed that the children are properly signed in/out. All staff present during today's inspection have a fingerprint clearance and are associated to YMCA of Superior California- Sacramento Central #340311102. LPA observed health screening reports with TB test and required MMR and TDAP vaccines. At least one staff member present today has current Pediatric CPR and First Aid. At least one staff member present today has a current AB1207 mandated reporter training certificate.

LPA verified the annual fees are current.

Report continues on 809-C.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2019
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: YMCA OF SUPERIOR CALIFORNIA - ZAMORA ELEMENTARY
FACILITY NUMBER: 573616914
VISIT DATE: 12/05/2019
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This provider is not currently providing IMS services to children in care. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417.

When any IMS is provided, a Plan for Providing 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.

This facility evaluation report was reviewed and discussed with the Director. An exit interview was conducted. A Notice of Site Visit was provided and should remain posted for a period of 30 days for parental review. The Director was encouraged to visit the Department's website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to child care centers.

In the areas that were evaluated, no deficiencies were cited during the inspection.

SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2019
LIC809 (FAS) - (06/04)
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