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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304270419
Report Date: 11/02/2023
Date Signed: 11/02/2023 10:17:18 AM

Document Has Been Signed on 11/02/2023 10:17 AM - 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 PETERSON PROGRAM CENTERFACILITY NUMBER:
304270419
ADMINISTRATOR:KRISTA ORPITELLIFACILITY TYPE:
840
ADDRESS:20661 FARNSWORTH LANETELEPHONE:
(714) 536-0068
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 127TOTAL ENROLLED CHILDREN: 127CENSUS: 0DATE:
11/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Director Jordyn Nelson TIME COMPLETED:
11:00 AM
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The purpose of this inspection was to conduct an unannounced visit due to a self-reported incident report received on 11/01/2023. Licensing Program Analyst (LPA) Romy Castanon met with Director Jordyn Nelson. There were no children present at the time of LPA’s visit. A review of the Facility Personnel Report Summary on 11/02/2023 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, LPA Castanon interviewed the Director who provided staff and children’s rosters. LPA also obtained attendance sheets.


Due to insufficient information available at this time further interviews need to be conducted.

Exit interview was conducted with Director Jordyn Nelson. The Notice of Site Visit was posted. Director was advised the Notice of Site Visit must be posted for 30 days. (End of Report)
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Romelia M Castanon
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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