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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334820558
Report Date: 09/05/2023
Date Signed: 09/05/2023 04:08:37 PM

Document Has Been Signed on 09/05/2023 04:08 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:CORONA-NORCO FAMILY YMCA-YOUTH CENTER AT HARADAFACILITY NUMBER:
334820558
ADMINISTRATOR:BERTHA ESTRADAFACILITY TYPE:
840
ADDRESS:12884 OAKDALE STREETTELEPHONE:
(951) 736-9622
CITY:CORONASTATE: CAZIP CODE:
92880
CAPACITY: 70TOTAL ENROLLED CHILDREN: 70CENSUS: 42DATE:
09/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Bertha Estrada, Site Supervisor TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts(LPAs) Elyse Jones arrived at the facility to conduct a Case Management inspection for the purpose of addressing separate matters that were discovered during an inspection at the facility. During record review it was discovered the facility was not in compliance with the Reporting Requirements regulation.

See LIC 809-D for deficiency cited.


Exit interview conducted and report was reviewed with Bertha Estrada, Site Supervisor. A Notice of Site Visit was given and must remain posted on, or immediately adjacent to the interior of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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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Document Has Been Signed on 09/05/2023 04:08 PM - It Cannot Be Edited


Created By: Elyse Jones On 09/05/2023 at 03:21 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: CORONA-NORCO FAMILY YMCA-YOUTH CENTER AT HARADA
FACILITY NUMBER: 334820558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2023
Section Cited
CCR
101212(d)(1)(C)

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(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addtion, a written report containing the information
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Based on the interviews and record review, the Licensee did not meet the Reporting Requirements regulation which poses a potential Health, Safety & Personal Rights risk to the children in care.
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specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.(1) Events reported shall include the following: (C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child
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Site Supervisor agrees to conduct a staff training with on but not limited to Reporting Requirements. Training agenda must be submitted by POC due date on 9-12-2023. Once training is completed a sign in sheet must be submitted to the Department with 24 hours.

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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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2023


LIC809 (FAS) - (06/04)
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