370805284-3-11-2026-20-CC-SZAA-DS3KBS-20260311074601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370805284
Report Date: 03/11/2026
Date Signed: 03/11/2026 07:46:27 AM

Document Has Been Signed on 03/11/2026 07:46 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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME:	SOUTH BAY FAMILY YMCA - ROSEBANK ELEMENTARY		FACILITY NUMBER:	370805284
ADMINISTRATOR/ DIRECTOR:	AL JIREH CAUSAPIN		FACILITY TYPE:	840
ADDRESS:	80 FLOWER STREET		TELEPHONE:	(619) 422-8329
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91910
CAPACITY: 70	TOTAL ENROLLED CHILDREN: 12	CENSUS: 6	DATE:	03/11/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	06:10 AM
MET WITH:	Alex Moreno		TIME VISIT/ INSPECTION COMPLETED:	08:00 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 03/11/2026 at 6:10AM Licensing Program Analyst, Saul Zazueta conducted an unannounced annual inspection and met with Teacher, Alex Moreno. LPA disclosed the purpose of the inspection and toured the inside and outside of the facility. This is a before school program that operates year-round. Days and hours of operation are Monday – Friday, 6:00AM to 8:45AM. There is one classroom in operation. There were three (3) staff members and six (6) children present during the time of inspection. Furniture and equipment in the classrooms were observed to be in good condition, free of sharp, loose, or pointed parts. The surface of the outdoor activity space is maintained, is in safe condition and is free of hazards. This program does not utilize any high climbing equipment or slides. The outdoor area has no shaded rest areas, but shade is not needed during the hours the program operates. Toilet and handwashing equipment are in safe and sanitary operating condition. Floors in the facility are clean and safe. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available both indoors and outdoors. LPA and facility staff were unable to locate a functioning carbon monoxide detector that meets statutory requirements during the time of inspection. The last fire/disaster drill was conducted and documented on 02/25/2026. Children receive snacks and lunch by means of the school the program operates in. Menus are posted monthly. Food preparation areas are clean and safe. Notation of children’s allergies is accessible. All food is protected against contamination, and any contaminated food is discarded immediately. A review of staff records on this date indicates facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions.

NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Saul Zazueta
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/11/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026

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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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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: SOUTH BAY FAMILY YMCA - ROSEBANK ELEMENTARY	FACILITY NUMBER: 370805284
	VISIT DATE: 03/11/2026

NARRATIVE

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Moreno stated there are no bodies of water or on the premises and LPA did not observe any bodies of water. Moreno stated there are no firearms, weapons, or ammunition allowed or stored on the premises. Disinfectants, cleaning solutions, medication and other hazardous items are made inaccessible to children. No poisons were observed during the inspection.

Moreno was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

All required notices, forms and license(s) were posted. Capacity and limitations as specified on the license are being maintained. At least one person trained in EMSA approved Pediatric CPR and First Aid is present when children are at the facility or at offsite activities. The name of the childcare center director or fully qualified teacher, designated to act in the director’s absence, has been reported to the Department. Children are under supervision, including visual supervision, of a teacher at all times. The person who signs the child in/out of the facility shall use their full signature and record the time of day. Sign in/out sheets reviewed and observed by the LPA meet this regulation. Facility maintains a ratio of one teacher supervising no more than 14 children in care. All required documentation is completed and was reviewed.

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). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

LPA reviewed a sample of children’s files and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child and medical assessment. LPA reviewed a sample of staff files and observed files were complete with health screening, immunization records for influenza, pertussis, and measles, and current documentation of completed mandated reporter training.

NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Saul Zazueta
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/11/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026

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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: SOUTH BAY FAMILY YMCA - ROSEBANK ELEMENTARY	FACILITY NUMBER: 370805284
	VISIT DATE: 03/11/2026

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

LPA reviewed with Moreno the LIC 311A, Records to Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

Moreno was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

LPA and Moreno discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, Mandated Reporter Training, Forms and Regulations, Safe Sleep in Childcare, Lead Poisoning Facts, Guardian and California Megan’s Law (www.meganslaw.ca.gov).

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, one (1) deficiency is being cited; see LIC809D.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with teacher Alex Moreno.

NAME OF LICENSING PROGRAM MANAGER: Tulam Vu
NAME OF LICENSING PROGRAM ANALYST: Saul Zazueta
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/11/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2026 07:46 AM - It Cannot Be Edited

Created By: Saul Zazueta On 03/11/2026 at 07:34 AM

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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: SOUTH BAY FAMILY YMCA - ROSEBANK ELEMENTARY	FACILITY NUMBER: 370805284
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.954

Licensure Requirements

Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the facility did not comply with the section cited above in that there was no carbon monoxide detector present in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/20/2026
	Plan of Correction
1 2 3 4	Facility Representative stated that they will purchase and install a carbon monoxide detector and submit proof of installation to the San Diego Regional Office by 03/20/2026.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Tulam Vu
NAME OF LICENSING PROGRAM MANAGER:

	Saul Zazueta
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026

LIC809 (FAS) - (06/04)

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