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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300605643
Report Date: 09/18/2025
Date Signed: 09/18/2025 03:23:06 PM

Document Has Been Signed on 09/18/2025 03:23 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:YMCA-MOFFETT PROGRAM CENTERFACILITY NUMBER:
300605643
ADMINISTRATOR/
DIRECTOR:		GUZMAN, JOSEFACILITY TYPE:
840
ADDRESS:8800 BURLCRESTTELEPHONE:
(714) 964-1870
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 138TOTAL ENROLLED CHILDREN: 138CENSUS: 66DATE:
09/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Jose GuzmanTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 09/16/2025, Licensing Program Analyst (LPA) Olivia Meza conducted an initial case management inspection to follow up on a self reported unusual incident that was submitted to CCL Regional Licensing Office on 08/22/2025. LPA Met with Jose Guzman A tour of the facility was conducted, and census was taken: LPA observed sixty six (66) school age children in individual classrooms with six (5) teachers.

According to Krista Poitras, Senior Program Director The unusual incident occurred on 8/21/25 that stated C1 (Child one) was given prescription medication that belonged to S1 (Staff one). C1 did not have the medication prescribed to C1 during the time of the incident.

During today's inspection, LPA Meza collected and reviewed documentation of: LIC9221 Parent Consent for Administration of Medications and Medication Chart, Parent Notification for the Administration of Medicine at School, Incidental Medical Services Individual Plan of Action, Parent/Guardian and Authorized Health Care Provider Request for Medication, and Parent/Guardian Request for Administration of Medication.

LPA Discovered that S1 and S2 involved during the incident on 8/21/25 are no longer employed at the facility. The parents of C1 were made aware that same day that an incident occurred on 8/21/25. The Director stated that the medication for C1 was requested and from the guardians of C1. On the date of 9/18/25 LPA observed that the medication for C1 Includes the name of the prescribing physician, and instructions and is stored properly. The Executive Director, Elizabeth Medina stated that on the date of August 28th 2025 an Emergency Staff Meeting was held to review the Retraining of Medication and Incidental Medical Services.

LPA reviewed and collected documentation of staff statements and reviewed the incident report submission.

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NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Olivia Meza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: YMCA-MOFFETT PROGRAM CENTER
FACILITY NUMBER: 300605643
VISIT DATE: 09/18/2025
NARRATIVE
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LPA Meza informed Director, Jose Guzman that this report dated 09/18/25 documents Type A citations which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

LPA Meza also informed the Director, Jose Guzman to provide a copy of this licensing report dated 09/18/25 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the Director, Jose Guzman. A notice of site visit was given and must remain posted for 30 days.

end of report.

NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Olivia Meza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/18/2025 03:23 PM - It Cannot Be Edited


Created By: Olivia Meza On 09/18/2025 at 02:51 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: YMCA-MOFFETT PROGRAM CENTER
FACILITY NUMBER: 300605643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2025
Section Cited
CCR
101226(e)(3)(A)(B)

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101226 Health-Related Services (e)(3)(A)(B) Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician... in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child.
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Facility has provided documentation of the LIC 9221.LPA observed prescription medication of C1 with documentation of approval and instructions from the child's authorized representative for the administration of the medication to the child in accordance with the label directions as prescribed by the child's physician.
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This Requirement was not met as evidenced by: C1 was provided medication that was prescribed to S1.
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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.
Martha Malane
NAME OF LICENSING PROGRAM MANAGER:
Olivia Meza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2025


LIC809 (FAS) - (06/04)
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