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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198017013
Report Date: 11/13/2023
Date Signed: 11/13/2023 03:10:04 PM

Document Has Been Signed on 11/13/2023 03:10 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 LOS CERRITOSFACILITY NUMBER:
198017013
ADMINISTRATOR:MICHELE JANSSENFACILITY TYPE:
840
ADDRESS:15530 WOODRUFF AVENUETELEPHONE:
(562) 925-1292
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 80TOTAL ENROLLED CHILDREN: 55CENSUS: 15DATE:
11/13/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Michelle Janssen, Facility Representative (FR)TIME COMPLETED:
04:00 PM
NARRATIVE
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On 11/13/2023 at 3:00 PM an Unannounced Case Management inspection was conducted by Licensing Program Manager Denise Gibbs and Licensing Program Analyst (LPA) Katrina Chicote for the purpose of serving an Immediate Exclusion for Sijifredo Saucedo, facility employee. Upon arrival Licensing Staff, announced purpose of visit and was granted entry to facility by Facility Representative (FR). LPA observed 15 school age children with four staff. Licensing Staff were provided guided tour of the facility by Michelle Janssen, (FR).

FR was served with the following by Licensing Program Manager Denise Gibbs:
· ORDER TO INFORM INDIVIDUAL OF IMMEDIATE EXCLUSION FROM ALL FACILITIES: Sijifredo Saucedo
· How to appeal
· Government Code 11522
· A sealed certified letter was left with Facility Representative
· An additional certified letter will be mailed to the address provided for Sijifredo Saucedo

Upon review, LPA did not observe incident in regards to arrest of individual to be reported to The Department. Per Title 22 Regulations, unusual incidents such as these are required to be reported to The Department within 24 hours via phone call and written report within seven days. A Type B citation was issued for violation.
LPA and LPM advised FR that Sijifredo Saucedo is excluded from YMCA GLB Cerritos and any other licensed facilities by Department of Social Services. Licensee and Sijifredo Saucedo have 15 days to submit an appeal. The address for the appeal was provided to FR. Licensing staff served the exclusion letter to Michelle Janssen, Facility Representative. Sijifredo Saucedo was not observed at the facility and FR has agreed to comply. Report Continues - Page 1 of 2
SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
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 3
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 LOS CERRITOS
FACILITY NUMBER: 198017013
VISIT DATE: 11/13/2023
NARRATIVE
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The following citation is being cited today on the attached 809D.

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


Exit interview was conducted with Facility Representative, Michelle Janssen.
Report Ends - Page 2 of 2
SUPERVISORS NAME: Denise Gibbs
LICENSING EVALUATOR NAME: Katrina Chicote
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/13/2023 03:10 PM - It Cannot Be Edited


Created By: Katrina Chicote On 11/13/2023 at 01:16 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 LOS CERRITOS
FACILITY NUMBER: 198017013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2023
Section Cited
CCR
101212(d)

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101212(d) Reporting Requirements
... operation of the child care center of any of the events... a report shall be made to the Department...containing the information specified... within seven days following the occurrence.. This regulation was not met as evidenced by:
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FR states they will create a plan for reporting these types of incidents and watch Department website on reporting requirements (https://ccld.childcarevideos.org/child-care-center-operators/child-care-reporting-requirements/) and provide plan and summary to Department by POC date.
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Based on LPA record review and interview the above regulation was not met as evidenced by it not being reported. FR states that they were not notified at this facility of individual's felony arrest and therefor did not report. This is a potential health, safety, and personal rights risk to children 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:Denise Gibbs
LICENSING EVALUATOR NAME:Katrina Chicote
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
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