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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198001217
Report Date: 10/08/2025
Date Signed: 10/08/2025 04:22:39 PM

Document Has Been Signed on 10/08/2025 04:22 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: 31DATE:
10/08/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Facility RepresentativeTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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On 10/08/2025, Licensing Program Analyst (LPA) Jonnisha Culbert conducted an unannounced case management annual continuation inspection at the facility noted above and met with facility representative. LPA stated the purpose of today’s visit is to complete the required 3-year inspection. This is a school-age program located on the campus of Madison Elementary School. The facility is licensed for room B30 and B31. Per facility representative, room B30 is the only room that is currently used by children. Per facility representative, the program operates Monday through Friday from 2:00 pm to 6:00 pm with early dismissal on Thursdays at 1:36 pm. Present at the time of today’s inspection were facility representative, two staff, and thirty-one children.

This report reflects information collected on 09/29/2025 and 09/30/2025.

The following documents are posted in a prominent, publicly accessible area at the facility: Facility License, Menu, Child Passenger Restraint System Poster (PUB 269), Notification of Parents' Rights (PUB 393), Emergency Disaster Plan (LIC 610), Personal Rights (LIC 613A), Daily Activity Schedule, and Earthquake Preparedness (LIC 9148).



Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. LPA inspected boys’ and girls’ restrooms sinks and toilets for availability and good repair. General sanitation was observed. LPA observed individual portable storage hooks used for children’s belongings. There was no napping equipment to be inspected.

Per facility representative, the isolation area is near the corner where the books are located. Children will wait there with staff until a parent/guardian pick them up.

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2025
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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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)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SITE
FACILITY NUMBER: 198001217
VISIT DATE: 10/08/2025
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Availability of indoor and outdoor drinking water was observed in classroom water jug and disposable cups. Per facility representative, the jug is cleaned weekly and filled with water daily. LPA verified that the lead testing was completed in accordance with the written directive outlined in Provider Information Notification (PIN) 21-21.1-CCP. Children utilize the school’s playground for outdoor play.

The facility provides the children with snacks daily. Per facility representative, no snacks are prepared at the facility, and snacks are purchased and delivered to them daily. LPA reminded facility representative to ensure that there are enough snacks for children who want extra. All storage containers for solid waste did not have tight-fitting covers. LPA reminded facility representative that all containers used for storage of solid wastes, including moveable bins, shall have a tightfitting cover that is kept on; shall be in good repair; and shall be leakproof and rodent-proof.



LPA checked for safety items. The facility has a carbon monoxide detector that was tested and is operable. The fire extinguisher is fully charged and was last serviced on July 15, 2025. First Aid supplies were observed. Per facility representative, no child currently enrolled requires medication. LPA reminded facility representative of incidental medical services (IMS) policy. During the inspection, the facility roster was not reviewed. LPA reminded facility representative to ensure that the facility roster include all required information for currently children enrolled, and for children who are no longer enrolled. LPA observed disaster drill logs. The last drill was conducted on 09/12/2025. This is a potential safety risk to persons in care. LPA reminded licensee that drills are to be conducted every six months. This facility does not provide transportation.

LPA conducted record reviews of two (2) child’s record and six (6) personnel records for completeness. LPA observed that all Departmental forms (licensing forms), for children, were replaced with YMCA’s forms. Based on staff records, no staff has valid Pediatric first aid and CPR/AED certification (Please review report written on 09/30/2025 for more information). LPA reminded facility representative that at least one employee must maintain a valid pediatric CPR and First Aid certificate. One out of three staff records reviewed (on 09/30/2025) did not have a valid mandated reporter training (Please review report written on 09/30/2025 for more information). LPA reminded facility representative that mandated reporter training must be completed every 2 years. Mandated reporter training is available at www.mandatedreprterca.com. LPA observed that six out of six staff records reviewed were missing required forms (immunizations) or had an invalid certification
NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SITE
FACILITY NUMBER: 198001217
VISIT DATE: 10/08/2025
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(expired Pediatric first aid CPR/AED or Mandated reporter certificates). LPA remind facility representative to ensure that all required forms are in staff files and are available for review upon the Departments request.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

The facility representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.
For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP).
LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/
NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SITE
FACILITY NUMBER: 198001217
VISIT DATE: 10/08/2025
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with facility representative.
NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC809 (FAS) - (06/04)
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