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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423040
Report Date: 10/07/2022
Date Signed: 10/07/2022 01:56:48 PM

Document Has Been Signed on 10/07/2022 01:56 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:YMCA EASTLAKE CENTERFACILITY NUMBER:
013423040
ADMINISTRATOR:LOVETTE TRAMMELFACILITY TYPE:
850
ADDRESS:1612-45TH AVETELEPHONE:
(510) 370-2966
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: DATE:
10/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jessica BoatnerTIME COMPLETED:
02:15 PM
NARRATIVE
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On October 7, 2022 Licensing Program Analysts (LPAs) Indira Loza and Nyeesha Blount and Licensing Program Manager (LPM) Mayla Mendoza arrived at the facility to conduct a case management visit as a direct result to an Unusual Incident report received in our office.

Based on interviews conducted, it was determined that a staff member grabbed and pulled the child around the playground. This is a Type A violation of section 101223(a)(3).

The Director must provide a copy of this report to all parents of children currently enrolled, and the parents of newly enrolled children in the next 12 months. In addition, Form LIC 9224 (Acknowledgment of receipt of Licensing Reports) must be signed by each parent and placed in each child's file.

A copy of the LIC 9224 is being provided to the Director during the inspection.

Exit Interview conducted with Director Boatner and Area Manager Monica Williams.

Appeal Rights and report provided.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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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Document Has Been Signed on 10/07/2022 01:56 PM - It Cannot Be Edited


Created By: Indira Loza On 10/07/2022 at 12:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: YMCA EASTLAKE CENTER
FACILITY NUMBER: 013423040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2022
Section Cited
CCR
101223(a)(3)

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Personal Rights - To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication
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Director shall re-train staff on Personal Rights.
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or aids to physical functioning. This requirement was not met as evidenced by: a staff member grabbed and pulled the child around the playground. This poses an immediate risk to the health and safety of the children in care.
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022


LIC809 (FAS) - (06/04)
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