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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197408601
Report Date: 11/28/2022
Date Signed: 12/06/2022 12:43:59 PM

Document Has Been Signed on 12/06/2022 12:43 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:SANTA MONICA FAMILY YMCA CHILD DEVELOPMENT CENTERFACILITY NUMBER:
197408601
ADMINISTRATOR:LINA JIMENEZFACILITY TYPE:
830
ADDRESS:1332 SIXTH STREETTELEPHONE:
(310) 393-2721
CITY:SANTA MONICASTATE: CAZIP CODE:
90401
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 16DATE:
11/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Maurreen MorrisonTIME COMPLETED:
11:00 AM
NARRATIVE
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On 11/28/2022 Licensing Program Analyst (LPA) Judy Laureano conducted a case management inspection to ensure facility is meeting all required regulations regarding facility's Toddler Option in an Infant Care Center- 101417. LPA explained the purpose of the inspection. There were 16 children in care and 3 staff present.

Based on observation and interviews, facility fails to have a clear written permission from the child’s authorized representative for the placement of the child in the toddler program.



LPA issued a type B citation and Notice of Site Visit was issued and a copy of this report was given to Facility director, Maureen Morrison.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE: DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/28/2022
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 12/06/2022 12:43 PM - It Cannot Be Edited


Created By: Judy Laureano On 11/28/2022 at 09:30 AM
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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: SANTA MONICA FAMILY YMCA CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 197408601

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/28/2022
Section Cited
CCR
101417(a)(1)

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101417-Toddler Component in an Infant Care Center
(a) Licensees serving infants may create a special program component for children who are between 18 months and 36 months ... in addition to those specified in Health and Safety Code section 1596.956.
(1) The infant care center shall obtain written permission from the child's authorized representative for the placement of the child in the toddler program.
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Facility agrees to make corrections to publications and/or forms that are given to parents acknowledging the child is participating in the toddler program. Revised forms will be sent to LPA via email by 12/2/2022
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This requirement is not met as evidenced by: based on record review and interviews, facility does not obtain a clear written permission for child to participate in the toddler program which pose which poses a potential health, safety or personal rights risk to persons 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:Claudia Escobedo
LICENSING EVALUATOR NAME:Judy Laureano
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022


LIC809 (FAS) - (06/04)
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