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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300611774
Report Date: 05/17/2022
Date Signed: 05/17/2022 05:00:55 PM

Document Has Been Signed on 05/17/2022 05:00 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:YMCA-HAWES PROGRAM CENTERFACILITY NUMBER:
300611774
ADMINISTRATOR:PEREZ, EMILYFACILITY TYPE:
840
ADDRESS:9682 YELLOWSTONE DR.TELEPHONE:
(714) 964-7011
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 96TOTAL ENROLLED CHILDREN: 78CENSUS: 42DATE:
05/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:DirectorTIME COMPLETED:
05:30 PM
NARRATIVE
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On 5/17/22 Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted a case management of the facility for an incident which was self reported by the facility representative to our office on 5/13/22. The Covid-19 Emergency Response questionnaire was answered. LPA met with director, Emily Perez.There were a total of 42 children and 4 staff including the director observed.

A review of staff records on this date indicated that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.
According to the facility self report, it states: a 6 year old child was found out of the YMCA portable (Y2) unattended. A witness who was coming to the YMCA recognized the child and brought the child back to YMCA.

Today LPA discussed the incident with the director, Emily Perez. LPA interviewed one staff, and four children who had knowledge regarding the incident. Staff # 1 stated that she was in the classroom with less than 12 school age children in Y2. Staff # 1 stated she did not notice the 6 year old child left the classroom but saw a witness brought the child back. Staff # 2 also stated she was in the room but did not see the child left. Staff # 2 saw a witness brought the child back to YMCA. Staff # 1 stated she was giving a 10 minutes break to the staff in charge of the 6 year old child.(staff # 3). It is not cleared how long the child was left unattended. According to staff # 1 this incident happened during the 10 minutes break of the staff # 3. Staff # 1 stated the absence of supervision must have occurred for couple of minutes. One child stated seeing 6 year od child got out of the classroom but could not tell for how long the child was gone. Child stated seeing the 6 year old came back with a witness. Three other children did not disclose any information. The incident happened around 4:45 pm. LPA attempted to contact the witness but no successful. LPA measured the
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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: YMCA-HAWES PROGRAM CENTER
FACILITY NUMBER: 300611774
VISIT DATE: 05/17/2022
NARRATIVE
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distance from the classroom and the area the child was found. It was estimated 200 feet.

Based on the information obtained through the staff # 1, staff # 2, and one child regarding the incident today, 6 year old child left the YMCA portable while the staff did not notice the child left. However the length of the time of absence of supervision is unknown. According to interviews the duration of absence might have happened couple of minutes.

Section 101229(a)(1 Responsibility for Providing Care and Supervision Type A was cited on LIC 809D.
An immediate civil penalty of 500.00 is hereby assessed for absence of supervision for today and 100.00 per day until corrected.


Upon receipt of Type A violations, the licensee shall post and provide copies of the report to parents/guardians of the children in care at the facility, and to the parents/guardians of children newly enrolled at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. The Notice of Site Visit was posted. 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.

Exit interview was conducted with director, Emily Perez.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/17/2022 05:00 PM - It Cannot Be Edited


Created By: Mahnaz Malek On 05/17/2022 at 04:10 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-HAWES PROGRAM CENTER
FACILITY NUMBER: 300611774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2022
Section Cited
CCR
101229(a)(1)

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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, except as specified in Sections 101216.2(e)(1) and 101230(c)(1)..........................
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The director agreed to send a statement signed by all the staff acknowledging the visual supervision of children at all times. The statement will be sent to our office by the due date of 5/18/2021. The director will also write a plan to prevent of happening such
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Based on self report, interviews with staff and one child, a 6 year old child left the classroom for few minutes and a witness brought the child back. The facility failed to meet the above Regulations. This is an immediate risk to the health and safety of children in care.
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incident in the future.
An immediate civil penalty of 500.00 is hereby assessed for absence of supervision for today and 100.00 per day until corrected.

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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:Rina Lopez
LICENSING EVALUATOR NAME:Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022


LIC809 (FAS) - (06/04)
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