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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494850
Report Date: 02/04/2025
Date Signed: 02/04/2025 03:37:13 PM

Document Has Been Signed on 02/04/2025 03:37 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:BURBANK YMCA HORACE MANN CHILDRENS CENTERFACILITY NUMBER:
197494850
ADMINISTRATOR/
DIRECTOR:		DIERIK GONZALEZFACILITY TYPE:
830
ADDRESS:3401 SCOTT ROADTELEPHONE:
(818) 729-1650
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 9DATE:
02/04/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Interim Director / Lorena Castro
Associate Executive Director / Stephen Francisco		TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 2/4/25, at 12PM, Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Case Management Visit to this facility. There were 5 children with 2 staff observed in the infant program and 4 children and 2 staff observed in the toddler program.

During a cite visit conducted at the facility on 2/4/25, LPA discovered multiple individuals working at the facility prior to requesting a transfer of a criminal record clearance as specified in Section 101170(f).
This poses a potential health, safety or personal rights risk to persons in care.

The following deficiency listed on the attached deficiency page is being cited in accordance with California
Code of Regulations Title 22.

The Notice of Site Visit must remain posted for 30 days during the hours of operation after each site visit by a
licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

Exit interview was conducted with Lorena Castro, Interim Director, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role.
SUPERVISORS NAME: Rita Ramos
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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 02/04/2025 03:37 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 02/04/2025 at 02:54 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: BURBANK YMCA HORACE MANN CHILDRENS CENTER
FACILITY NUMBER: 197494850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2025
Section Cited
CCR
101170(e)(2)

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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 101170(f).
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Licensee will ensure all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 101170(f). Licensee will submit
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This requirement was not met as evidenced by: During a cite visit conducted at the facility on 2/4/25, LPA discovered multiple individuals working at the facility prior to requesting a transfer of a criminal record clearance as specified in Section 101170(f).
This poses a potential health, safety or personal rights risk to persons in care.
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proof of correction to CCL showing all individuals found in violation of this section are associated to the facility roster. POC must be submitted to CCL by the end of business day on 2/5/25.

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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:Rita Ramos
LICENSING EVALUATOR NAME:Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
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