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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846321
Report Date: 10/15/2025
Date Signed: 10/15/2025 04:33:23 PM

Document Has Been Signed on 10/15/2025 04:33 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:YMCA YOUTH CENTER PEACE LUTHERAN CHURCHFACILITY NUMBER:
334846321
ADMINISTRATOR/
DIRECTOR:		TOSHA PESICFACILITY TYPE:
850
ADDRESS:280 E ONTARIO AVETELEPHONE:
(951) 735-3080
CITY:CORONASTATE: CAZIP CODE:
92879
CAPACITY: 45TOTAL ENROLLED CHILDREN: 0CENSUS: 28DATE:
10/15/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Shauna Smith-Fluellen, DirectorTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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On the above date and time, a case management visit is being conducted in response to the receipt of an unusual incident report (UIR) from the facility. The UIR was received by the licensing agency on 10/10/2025. It indicates that on 10/10/2025, emergency services were rendered for a subject child in care, due to an allergic reaction of food served to the child. The LPA was greeted and granted entry by Director Shauna Smith-Flullen. The LPA took a census of 24 children in care of 5 staff.

The LPA made observations, reviewed records, and conducted interviews with pertinent parties relevant to the incident. Information gathered revealed that a subject child was provided with a meal which included a food item they are allergic to. Pertinent parties stated emergency services were requested and rendered as a result of the subject child consuming the food item. Pertinent parties interviewed stated only one substitute food item was prepared for the child by the food service company, on the date of the incident. By admission, pertinent parties stated the agency representatives were aware of the subject child’s restricted food items, which were documented and on file. A review of records confirmed 3 restricted food items were listed on the menu for two separate meals on the date of the incident.

It was determined that the agency acted appropriately by rendering services on site, while waiting for 1st responders to arrive. The agency also notified the authorized representative regarding the incident and self-reported the incident to the licensing department as required. However, due to the agency providing a restricted food item to the subject child and not ensuring alternative foods were offered to be served, the agency was determined to be in violation. Based on the information gathered, the following violations have been identified: 101227(a)(7)(B) Food Services.

See LIC809C page 2
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Susan Brewer
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: YMCA YOUTH CENTER PEACE LUTHERAN CHURCH
FACILITY NUMBER: 334846321
VISIT DATE: 10/15/2025
NARRATIVE
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LPA Susan Brewer informed the Director Shauna Smith-Flullen that this report dated 10/15/2025 documents a Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Susan Brewer informed the Director Shauna Smith-Flullen to provide a copy of this licensing report dated 10/15/2025 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report LIC9224, or other written statement, must be placed in the child's file for verification.

See LIC809D for cited deficiencies of the California Code of Regulations, Title 22, Div. 12. 101227(a)(7)(B) Food Services.

No civil Penalties were issued.

An exit interview was conducted, appeal rights discussed, and a copy of this report was provided to Director Shauna Smith Flullen.

A notice of site visit was given and must remain posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Ana Noble
NAME OF LICENSING PROGRAM ANALYST: Susan Brewer
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/15/2025 04:33 PM - It Cannot Be Edited


Created By: Susan Brewer On 10/15/2025 at 03:33 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: YMCA YOUTH CENTER PEACE LUTHERAN CHURCH
FACILITY NUMBER: 334846321

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2025
Section Cited
CCR
101227(a)(7)(B)

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101227 Food Services:(a)...child care centers providing meals to children, the following shall apply: (7) Modified diets prescribed by a child's physician; (B) A child shall not be served any food to which the child's record indicates he/she has an allergy.
This regulation was not met as evidenced by:
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The licensee agrees to submit a written plan of action to ensure compliance with Title 22 regulation101227(a)(7)(B) Food Services, describing implementation of the action plan to accomodate children enrolled with diet restrictions & submit to the department by 10/16/2025.
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Based on interview, record review, observation & by the licensee's own admission, on 10/10/2025 emergency medical services were required for a subject child due to the licensee providing a known, restricted food item during mealtime, which is an immediate risk to the health & safety of children in care.
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The licensee also agrees to submit of proof of staff participation in food service training, with a training curriculum to the department by fax, mail or e-mail by 10/23/2025.

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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.
Ana Noble
NAME OF LICENSING PROGRAM MANAGER:
Susan Brewer
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2025


LIC809 (FAS) - (06/04)
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