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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494851
Report Date: 12/07/2023
Date Signed: 12/07/2023 12:34:55 PM

Document Has Been Signed on 12/07/2023 12:34 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 CHILDRENS CENTER PRESCHOOLFACILITY NUMBER:
197494851
ADMINISTRATOR:ANGELA BUCKFACILITY TYPE:
850
ADDRESS:3401 SCOTT RDTELEPHONE:
(818) 729-1650
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 146TOTAL ENROLLED CHILDREN: 146CENSUS: 14DATE:
12/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Director / Dierik GonzalezTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joe Katrdzhyan and Elicia Calvillo conducted an unannounced Case Management Visit to this facility.

LPAs met with Director / Dierik Gonzalez, who guided LPAs on a tour of the facility. There were 14 children with 5 staff observed present.

LPAs discovered that the facility failed to report an incident that occurred on 10/31/23, involving a child (Child 1) who went missing and was later found in a classroom alone. Per Director / Dierik Gonzalez, the facility did not file an Unusual Incident/Injury Report (LIC 624) to CCL, per Title 22 Reporting Requirements, Section 101212.

During today's visit, the Director was asked to submit an Unusual Incident/Injury Report to CCL by no later than the end of business day on 12/7/23.

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 Dierik Gonzalez, 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: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2023
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 12/07/2023 12:34 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 12/07/2023 at 11:46 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: BURBANK YMCA CHILDRENS CENTER PRESCHOOL
FACILITY NUMBER: 197494851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2024
Section Cited
CCR
101212(d)(1)(C)

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Reporting Requirements. Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
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The Director will review Title 22, Regulation Section 101212 / Reporting Requirements and conduct an in-service training with all staff on the importance of ensuring compliance within this section. Copies of the training along with signatures of all attendees will be submitted to CCL by the POC due date of 1/8/24.
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Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement is not being met as evidenced by: LPAs discovered that the facility failed to report an incident that occurred on 10/31/23, involving a child (Child 1) who went missing and was later found in a classroom alone. Per Director / Dierik Gonzalez, the facility did not file an Unusual Incident/Injury Report (LIC 624) to CCL.
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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: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2023


LIC809 (FAS) - (06/04)
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