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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300610624
Report Date: 10/16/2024
Date Signed: 10/16/2024 01:52:19 PM

Document Has Been Signed on 10/16/2024 01:52 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:CENTRAL ORANGE COAST YMCA - MARINERS SCHOOLFACILITY NUMBER:
300610624
ADMINISTRATOR/
DIRECTOR:		MEDINA, ELIZABETHFACILITY TYPE:
840
ADDRESS:2100 MARINERS DRIVETELEPHONE:
(949) 548-6770
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 36TOTAL ENROLLED CHILDREN: 53CENSUS: 0DATE:
10/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Site Director, Matthew PellettTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cindy Nguyen conducted an unannounced case management incident inspection in response to a self-report Unusual Incident dated 10/04/2024. LPA met with Site Director, Matthew Pellett. LPA informed director about the purpose of the visit and conducted a walk through of the facility. At the time of the inspection, there were no children present. At 1:45pm, there was a total of 3 staff members and 12 children. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 10/04/24 a self-reported Unusual Incident Report (UIR) was filed with the Licensing Office. The facility reported that Child 1 (C1) and Child 2 (C2) were found in the restroom together.

During today's inspection, LPA interviewed two staff members, and review statements from the four staff. Staff #1(S1)’s statement stated staff was taking out the trash, walked to one bathroom, while Staff #2 (S2) was trying to grab the other bathroom trash, when S2 noticed the bathroom was locked, and up knocking two voices were heard. When it got unlocked it was discovered by (S2) that two children were in there. Staff #5 (S5) stated the children may have been in the restroom together for less than five minutes.

Based on the information gathered from the self-reported unusual incident report, interviews with two staff members, review statements from the four staff and a physical plant inspection. It was determined that the staff didn't observe the two children in the restroom together for about five minutes. California Code of Regulations, Title 22, Section 101229(a)(1) Responsibility for Providing Care and Supervision is being cited on the attached LIC 809D.

LPA Nguyen informed the director that this report dated 10/16/2024 documents a Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, and personal rights to the children in care. Continued on Page 2

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CENTRAL ORANGE COAST YMCA - MARINERS SCHOOL
FACILITY NUMBER: 300610624
VISIT DATE: 10/16/2024
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Also, LPA Nguyen informed director to provide a copy of this licensing report dated 10/16/2024 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 form the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224) or other written statement must be kept in the child's file for verification.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the licensing office within 15 business days. The facility representative was informed that the 'Notice of Site Visit' must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00.

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 01:52 PM - It Cannot Be Edited


Created By: Cindy Nguyen On 10/16/2024 at 12:58 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: CENTRAL ORANGE COAST YMCA - MARINERS SCHOOL
FACILITY NUMBER: 300610624

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time…This requirement is not met as evidenced by:
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Director agreed to submit training agenda, and staff sign in sheet to LPA email cindy.nguyen@dss.ca.gov. Supervising Children in Child Care Centers- California Child Care Licensing- ccld.childcarevideos.org.
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Based on the information gathered from the unusual incident report, interviews with two staff, and review statements from the four staff. The children were in the bathroom together for approximately five minutes without the supervision. This is an immediately safety 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:Patricia Magana
LICENSING EVALUATOR NAME:Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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