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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846321
Report Date: 07/06/2023
Date Signed: 07/06/2023 02:41:05 PM

Document Has Been Signed on 07/06/2023 02:41 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 PEACE LUTHERAN CHURCHFACILITY NUMBER:
334846321
ADMINISTRATOR:ART CABRERAFACILITY TYPE:
850
ADDRESS:280 E ONTARIO AVETELEPHONE:
(951) 735-3080
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 11DATE:
07/06/2023
TYPE OF VISIT:Case Management - Lead Testing/ExceedanceUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Art Cabrera, Program Director
Tosha Pesic, Site Supervisor		TIME COMPLETED:
02:50 PM
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Licensing Program Analysts (LPAs) Elyse Jones and Blanca Ruiz arrived at the facility to conduct a Case Management- Lead Testing Exceedance inspection to discuss testing results. A facility tour was given and census were taken.

During the inspection, LPAs toured and obtained photos of the water source that is being used to fill the portable hand washing station and the water source that is in the restroom being used for hand washing. As stated by Program Director, Art Cabrera and Site Supervisor,Tosha Pesic , the facility is using water bottles exclusively for drinking and food is delivered from the Main YMCA kitchen.

Art Cabrera was informed by LPAs if, after January 1, 2023, it is determined that any other sources of water are used for either drinking or food preparation, the facility would be subject to adverse action, including but not limited to being cited and having a plan of correction put in place for the required testing.

No deficiencies cited.

Additionally, the following resources were discussed and provided from PIN 21-21.1-CCP.

101700.6 Grant Funding for Qualifying Child care Centers

(a) Senate Bill 862, Chapter 449, Statutes of 2018 allocated $5 Million to the State Water Resources Control Board for testing and remediation of lead in the drinking water of Child Care Centers based on the following criteria:

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 PEACE LUTHERAN CHURCH
FACILITY NUMBER: 334846321
VISIT DATE: 07/06/2023
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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 the Art Cabrera and Tosha Pesic.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC809 (FAS) - (06/04)
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