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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334842335
Report Date: 10/10/2023
Date Signed: 10/10/2023 01:58:27 PM

Document Has Been Signed on 10/10/2023 01:58 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:YMCA YOUTH CENTER AT MERRILLFACILITY NUMBER:
334842335
ADMINISTRATOR:ULRICH, MARIFACILITY TYPE:
850
ADDRESS:312 S. MERRILL STREETTELEPHONE:
(951) 734-8026
CITY:CORONASTATE: CAZIP CODE:
92882
CAPACITY: 61TOTAL ENROLLED CHILDREN: 61CENSUS: 14DATE:
10/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:23 PM
MET WITH:Mary Ulrich, Site Supervisor TIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to conduct a Case Management inspection in response to the receipt of an Unusual Incident Report (UIR) from the facility. It documents an incident involving Child #1 who was sitting on a chair in the outdoor play area, fell off and broke his/her arm when Child #2 flipped the chair over. Interviews were conducted. Further information will be needed. Upon completion of the review, the outcome and/or recommendations will be provided to the licensee.

At the time of the inspection, LPA toured the facility, took census, and met with Mary Ulrich, Site Supervisor.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Mary Ulrich, Site Supervisor.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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