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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343626474
Report Date: 01/02/2025
Date Signed: 01/02/2025 11:42:11 AM

Document Has Been Signed on 01/02/2025 11:42 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:YMCA OF SUPERIOR CALIFORNIAFACILITY NUMBER:
343626474
ADMINISTRATOR/
DIRECTOR:		TIFFANY DAVIDSONFACILITY TYPE:
860
ADDRESS:1926 V STREETTELEPHONE:
(916) 457-9622
CITY:SACRAMENTOSTATE: CAZIP CODE:
95818
CAPACITY: 73TOTAL ENROLLED CHILDREN: 73CENSUS: 17DATE:
01/02/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Tiffany Davidson and Jessie ThomasTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On January 2, 2025, at approximately 8:30 AM Licensing Program Analyst (LPA) Pa Dao Vang and Licensing Program Manager (LPM) Seychelle De Luca met with Applicant Tiffany Davidson and Director Jessie Thomas for the purpose of an announced change of component pre-licensing inspection.

Applicant requests a license to serve a capacity of 73 children from age 6 weeks to 5 years old. Licensee is requesting 12 children (6 weeks to 24 months) for the Infant Room, 12 children (18 months to 36 months) for the Toddler Component Room, and 49 children (2 years old to 5 years old) for the Early Preschool and Preschool Rooms. The program will operate Monday through Friday from 7:00 AM to 6:00 PM.

Applicant acknowledges that the following documents must be posted at all times: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, car seat law, Effects of Lead Exposure brochure, menus, and daily schedule. LPA discussed the forms that must be in each child's file and each staff member's file. The facility will provide breakfast, lunch, and PM snack. Parents will provide formula and infant food with proper labels for the infant classroom.

INDOOR ACTIVITY SPACE:
There are 4 classrooms: Infant, Toddler Component, Early Preschool, and Preschool. All of these spaces are located near the corner of W Street and 19th Street in the building. LPA observed a sufficient amount of equipment, toys, chairs, and tables. There were 12 cribs in the infant napping room. There are first aid kit supplies and fully charged fire extinguishers. Applicant will purchase new trash cans with lids for the classrooms. LPA observed infant medications stored in the cabinet in the room. Applicant stated preschool medications are stored in the front office. Applicant stated there are no smoking, no poisons, and no firearms on the premises. There is a functional carbon monoxide detector located in the front room. LPA observed daily electronic sign in and sign out app and a binder.
Report continues on LIC809-C…
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: YMCA OF SUPERIOR CALIFORNIA
FACILITY NUMBER: 343626474
VISIT DATE: 01/02/2025
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LPA and LPM measured the all 4 classrooms. The total for Early Preschool and Preschool Rooms spaces contained a total of 1893.17 square feet, which is sufficient to accommodate 49 children. The total for Toddler Component Room space contained a total of 628.88 square feet, which is sufficient to accommodate 12 children. The total for Infant Room space contained a total of 471.85 square feet, which is sufficient to accommodate 12 children. There were 10 sinks located in the facility. LPA and LPM observed sinks in the Infant Room with a changing tables within arm’s length. There were six toilets, two urinals, one potty chair for children to use. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

OUTDOOR ACTIVITY SPACE:
There is one outdoor area for infants and toddlers on the property. Applicant stated this yard will be shared between infants and toddlers in the Toddler Component. The infant yard space measures a total of 809.65 square feet, which accommodates 11 children at a time. There is a separate outdoor area for preschool children. The preschool yard space measures a total of 6,576.87 square feet, which is sufficient to accommodate 49 children at a time. Applicant will submit a waiver request for an outdoor shared space with rotating classroom schedules for the infant and toddler children to use the shared yard. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

The outdoor spaces are separated from the infant/toddler and preschool yards with a gated fence that is at least four feet tall. LPA and LPM observed a sufficient amount of equipment and toys. There are no bodies of water on the premises. There are shaded areas supplied by structures, buildings, and trees. Application acknowledges staff must ensure children use age-appropriate equipment at all times.

The facility's Plan of Operation is located in the facility file. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department.

The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm. Report continues on LIC809-C…

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: YMCA OF SUPERIOR CALIFORNIA
FACILITY NUMBER: 343626474
VISIT DATE: 01/02/2025
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LPAs discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Applicant will submit a waiver request for infant sleep sack.

LPA and LPM discussed the following: 100% supervision is required at all times, including in the bathroom; personal rights; criminal record clearances, inspection authority; reporting requirements; staff to children ratios and capacity; staff qualifications; and maintaining buildings and grounds. LPA and LPM discussed with Applicant any changes that may occur regarding the Directors or an employee acting in the director's absence must be reported to department within 10 working days.

Applicant understands to pay the annual fees before the due date. The annual bill will be sent through the mail with facility number, pin, and the amount of it. Applicant can pay it through the department website at https://cdss.ca.gov/inforesources/community-care/licensing-fees . They may also pay in person in our office or mailing with check/Money Order/personal check to the address listed below:



CA Department of Social Services
MS 9-3-67
P.O. Box 944243
Sacramento, CA 94244-2430

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For childcare center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). Director stated the facility completed leading testing last year in 2023 with no lead exceedance. Director is working on renewing the Lead Testing by the end of this year and will email LPA the new results.
Report continues on LIC809-C…
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: YMCA OF SUPERIOR CALIFORNIA
FACILITY NUMBER: 343626474
VISIT DATE: 01/02/2025
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CONDITIONS REQUIRING CORRECTION PRIOR TO ISSUING A LICENSE:

1. A final review of the file by Licensing Program Manager (LPM) Seychelle De Luca.
2. Wavier request for sharing the infant and preschool yards to include the toddler children.
3. Waiver request for sleep sacks.
4. Pending documents (updated Parent Handbook, Admission Agreement, Director’s Health Screening, photo of the Toddler Component classroom set up.)
5. Put a latch on the Toddler Room door.
6. Purchase new mats and cots.
7. Purchase trash cans with tight fitting lids.
8. Waiver request for co-mingling for the first and last hour of the day (toddler and preschool children).

Once the above are completed, LPA will license the facility for 73 children. An exit interview was conducted and a copy of this report was provided to Applicant Tiffany Davidson and Director Jessie Thomas.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC809 (FAS) - (06/04)
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