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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198001217
Report Date: 09/30/2025
Date Signed: 09/30/2025 04:38:57 PM

Document Has Been Signed on 09/30/2025 04:38 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:YMCA GLB MADISON SITEFACILITY NUMBER:
198001217
ADMINISTRATOR/
DIRECTOR:		STARLYN JOHNSONFACILITY TYPE:
840
ADDRESS:2801 BOMBERRYTELEPHONE:
(562) 756-6808
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 60TOTAL ENROLLED CHILDREN: 31CENSUS: 29DATE:
09/30/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:43 PM
MET WITH:Facility RepresentativeTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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09/30/2025 at 1:43pm, Licensing Program Analyst Jonnisha Culbert conducted an unannounced case management annual continuation at the facility noted above. LPA met with facility representative and stated the purpose of today’s visit. The purpose of today’s visit is to continue the annual/random inspection that commenced on 09/29/2025. The following was observed on 09/29/2025:

At 3:48pm, during record review LPA J. Culbert observed that three out of three staff did not have Pediatric First Aid CPR/AED. Per facility representative, they have it. Representative presented LPA with a Red Cross Completion Certificate for Blood pathogen. This is a potential health and safety risk to person in care. LPA explained to facility representative that at least one staff member on the premises is required to have a valid Pediatric First Aid CPR/AED Training Certificate.

At 3:55pm, LPA J. Culbert observed that staff 1 did not have a valid mandated reporter certificate, immunization against measles and pertussis, and health screening (LIC 503) on their file. This is a potential safety risk to persons in care.

Due to time restraints the annual/random visit will be completed on a future date. During today’s visit, four type B citations were cited. Please see form LIC 809D for more information.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the facility representative.

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
Document Has Been Signed on 09/30/2025 04:38 PM - It Cannot Be Edited


Created By: Jonnisha Culbert On 09/30/2025 at 03:16 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: YMCA GLB MADISON SITE
FACILITY NUMBER: 198001217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of three staff was not immunized against pertussis and measles. During record review, LPA did not observe immunizations against pertussis and measles in staff 1's file. This posea a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2025
Plan of Correction
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Per faciity representative, they will obtain staff 1's immunizations against measles and pertussis and email a copy to LPA J. Culberet by plan of correction (POC ) daate.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above and one out of three staff did not have a mandated reporter certificate. During record review, LPA did not observe certificate in staff 1's file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2025
Plan of Correction
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Per facility representative, they will ensure that staff 1 complete manadated reprter training and email completion proof to LPA J. Culbert by plan of correction (POC) date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Jonnisha Culbert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/30/2025 04:38 PM - It Cannot Be Edited


Created By: Jonnisha Culbert On 09/30/2025 at 03:16 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: YMCA GLB MADISON SITE
FACILITY NUMBER: 198001217

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and intervieew, the licensee did not comply with the section cited above and three out of three staff do not have training in pediatric cardiopulmonary resuscitation and pediatric first aid which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2025
Plan of Correction
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Per facility representative, they will retrieve a valid pediatric first aid CPR/AED training certificate and email a valid completion certificate to LPA J. Culbert by plan of correction date (POC) date.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reveiw, the licensee did not comply with the section cited above and one out of three staff did not have a health screening. During record review, LPA did not observe health screening in staff 1's file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2025
Plan of Correction
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Per facility representative, they will ensure that staff 1 retrieve a health screening (LIC 503) completed by a licensed physician and email a copy to LPA J. Culbert by plan of correction date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Jonnisha Culbert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
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