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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 300607120
Report Date: 07/16/2026
Date Signed: 07/16/2026 03:04:08 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2026 and conducted by Evaluator Kathy Trinh
PUBLIC
COMPLAINT CONTROL NUMBER: 06-CC-20260508081958
FACILITY NAME:CAPISTRANO BEACH CITIES YMCA-AMBUEHLFACILITY NUMBER:
300607120
ADMINISTRATOR:COMER, SOPHIAFACILITY TYPE:
840
ADDRESS:28001 SAN JUAN CREEK RD.TELEPHONE:
(949) 493-5327
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:75CENSUS: 19DATE:
07/16/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Director, Sophia ComerTIME COMPLETED:
03:08 PM
ALLEGATION(S):
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Facility did not ensure that sharp objects were not accessible to children in care.
Facility did not follow reporting requirements.
INVESTIGATION FINDINGS:
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On 07/16/2026, Licensing Program Analyst (LPA), K. Trinh conducted an unannounced subsequent complaint inspection for the purpose of delivering findings for the complaint investigation that was initiated on 05/12/2026. Upon arrival, LPA met with Director, Sophia Comer and was led on a tour of the facility. LPA observed a total of 19 school-age children along with 2 staff.
A review of the Facility Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During today’s inspection the facility was operating within its licensed capacity and within compliance of staffing ratios.
On 05/08/2026, the Orange County Regional Child Care Licensing Office received a complaint with the following allegations: (1) Facility did not ensure that sharp objects were not accessible to children in care and (2) Facility did not follow reporting requirements.
(Continue to page 2)
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Tina Nguyen
LICENSING EVALUATOR NAME: Kathy Trinh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 06-CC-20260508081958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CAPISTRANO BEACH CITIES YMCA-AMBUEHL
FACILITY NUMBER: 300607120
VISIT DATE: 07/16/2026
NARRATIVE
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(Page 2)

Reporting party (RP) stated that Child 1 (C1) had access to a can opener multiple times during an incident. RP also shared that C1 has left the facility’s premises on multiple occasions. RP is unsure if the unusual incidents that occurred at the facility have been reported to the Department.

During investigation, LPA conducted interviews with five (5) staff, three (3) children, five (5) parents, and obtained pertinent documents.

Regarding allegation (1) Facility did not ensure that sharp objects were not accessible to children in care.

During record review, the Parent Communication Form written by the director on May 7, 2026, documented that C1 removed various items and emptied them onto the floor. C1 also threw multiple items at the one-on-one aide. Staff and the one-on-one aide attempted to redirect and deescalate C1 throughout the incident. The incident report further states that a phone call home was made. C1 was suspended from the program following the incident, pending a meeting with C1’s parent.

During staff interviews, three (3) of five (5) staff reported that sharp kitchen utensils are stored in a locked cabinet. However, Staff 3 (S3) stated that sharp utensils are kept in fabric cubby bins that are not secured or inaccessible to children. Staff 1 (S1) also reported that the kitchen contains a metal table with a sliding door where kitchen utensils (such as plates and bowls) are stored.

Staff 1, 3, and 5 stated that they were present during the incident and reported the following: C1 got upset while playing a game of chess and their behavior escalated, causing C1 to knock over various objects throughout the classroom. The rest of the staff and children in the classroom directed to go outside.

S1 added that C1 retrieved a can opener that was placed inside the metal table with a sliding door, which was unlocked. Staff attempted to redirect and deescalate C1. S1 was able to remove the can opener from C1 and secure it in the locked kitchen cabinet.

(Continue to page 3)

SUPERVISORS NAME: Tina Nguyen
LICENSING EVALUATOR NAME: Kathy Trinh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 06-CC-20260508081958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CAPISTRANO BEACH CITIES YMCA-AMBUEHL
FACILITY NUMBER: 300607120
VISIT DATE: 07/16/2026
NARRATIVE
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(Page 3)

S3 reported that C1 obtained a can opener from the kitchen area and put it against their skin, leaving red marks on their upper forearm. S3 removed the can opener from C1 and placed it on top of the refrigerator while continuing to assist C1. C1 climbed onto the refrigerator and regained access to the can opener. S3 and S1 then helped C1 down from the refrigerator and secured the can opener so it was no longer accessible.

Staff 5 (S5) added that they were with the group of children and staff that were directed to go outside. While inside the classroom, they do not recall seeing C1 obtain a can opener.

During observations, LPA observed that the metal kitchen table was accessible and contained non-sharp kitchen items and utensils. Sharp kitchen utensils, including but not limited to scissors and a can opener, were stored in a basket inside a locked cabinet.

LPA conducted parent interviews. The interviewed parents did not divulge any information pertaining to the allegation or express any concerns regarding care of the children. LPA also conducted children’s interviews. The children interviewed did not divulge any information pertaining to the allegation. LPA attempted to interview C1 but was unable to speak with them.

Regarding allegation (2) Facility did not follow reporting requirements.

During record review, LPA reviewed C1’s parent communication forms which document multiple elopement incidents. On December 2, 2025, at approximately 4:45 p.m., C1 showed behaviors or eloping and attempted to leave after being pushed. The parent communication form was signed by the director and C1’s authorized representative on December 2, 2025.

On April 6, 2026, at approximately 1:50 p.m., C1 knocked over and dumped out various objects in the classroom before running out of the classroom, climbing over the fence, and exiting the school boundary. The parent communication form was signed by the director and C1’s authorized representative on April 6, 2026.

(Continue to page 4)

SUPERVISORS NAME: Tina Nguyen
LICENSING EVALUATOR NAME: Kathy Trinh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 06-CC-20260508081958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CAPISTRANO BEACH CITIES YMCA-AMBUEHL
FACILITY NUMBER: 300607120
VISIT DATE: 07/16/2026
NARRATIVE
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(Page 4)

On April 8, 2026, at approximately 4:57 p.m., C1 jumped over the fence and ran toward the street. Staff caught up to C1 and brought them back onto campus. C1 then ran out again and attempted to jump the fence but was caught. C1’s authorized representatives were called, and C1 was suspended for five days. The form was signed by the director on April 8, 2026, and by C1’s authorized representative on April 10, 2026.

During staff interviews, the director stated that the incidents were only reported to their supervisor and the child’s parents. The director added that the incidents were not reported to the licensing department or any other agencies because staff were able to follow C1 throughout each incident.

LPA conducted parent interviews. The interviewed parents did not divulge any information pertaining to the allegation or express any concerns regarding care of the children. LPA also conducted children’s interviews. The children interviewed did not divulge any information pertaining to the allegation. LPA attempted to interview C1 but was unable to contact them.

Based on LPA’s observations, interviews and record review, the preponderance of evidence has been met; therefore, the allegations of (1) Facility did not ensure that sharp objects were not accessible to children in care and (2) Facility did not follow reporting requirements was found to be Substantiated. California Code of Regulations, Title 22, Division 12, Sections 101238 and 101212 are being cited. See LIC9099D for deficiency cited.

Exit interview was conducted. Notice of Site Visit was posted during the visit. Director was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.

Appeal Rights were explained. The Director was provided with a copy of the appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

End of report.

SUPERVISORS NAME: Tina Nguyen
LICENSING EVALUATOR NAME: Kathy Trinh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 06-CC-20260508081958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CAPISTRANO BEACH CITIES YMCA-AMBUEHL
FACILITY NUMBER: 300607120
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2026
Section Cited
CCR
101238
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101238 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children. This requirement is not met as evidence by:
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Director created a boundary line to help students visualize where they are and are not allowed to be. LPA also verified that the sharp kitchen utensils are locked in the cabinet. The metal sliding door is only used to store paper plates and cups.
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Based on interviews, the licensee did not comply with the section cited above in that, Child 1 (C1) was able to obtain a can opener, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
07/30/2026
Section Cited
CCR
101212
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101212 Reporting Requirements (d)... any of the events specified, a report shall be made to the Department... (C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement is not met as evidence by:
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Director stated that they will discuss the reporting requirements with their supervisor. LPA also provided the director with the reporting requirements regulations and will send LPA a written statement to confirm they understand the reporting requirements.
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Based on interviews, the licensee did not comply with the section cited above in that the incidents regarding Child 1’s (C1) elopement were not reported to the department which poses a potential health, safety or personal rights risk to persons 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: Tina Nguyen
LICENSING EVALUATOR NAME: Kathy Trinh
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2026
LIC9099 (FAS) - (06/04)
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