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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600371
Report Date: 11/15/2021
Date Signed: 11/15/2021 02:12:55 PM

Document Has Been Signed on 11/15/2021 02:12 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, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME:MISSION VALLEY YMCA - LONGFELLOW ELEMENTARY SCHOOLFACILITY NUMBER:
376600371
ADMINISTRATOR:DOMINIQUE KINGFACILITY TYPE:
840
ADDRESS:5055 JULY STREETTELEPHONE:
(619) 276-4206
CITY:SAN DIEGOSTATE: CAZIP CODE:
92110
CAPACITY: 125TOTAL ENROLLED CHILDREN: 79CENSUS: 46DATE:
11/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Alex BellTIME COMPLETED:
02:30 PM
NARRATIVE
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On 11/15/21 @ 1:20PM, Licensing Program Analyst (LPA) Nancy Diaz conducted an unannounced inspection in reference to a self-reported unusual incident that involved an 8-year old school-age child who was left unsupervised by staff for approximately 5 minutes. Teacher in charge left behind a child unattended in the bathroom. LPA met with Alex Bell, Site Director.

Observed present today were 46 school-age children with staff Stephanie Mondragon; Davion Dewberry; Regan Salas; Destinee Martinez & Saray Martinez.

Type A deficiency was cited. Type A deficiency if not corrected poses an immediate risk to the health, safety or personal rights of children in care.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Exit interview was conducted with Mr. Bell. Appeal rights were discussed. A written copy of the appeal rights and Licensing report was provided to Mr. Bell today. A notice of site visit was provided today and was observed posted by Mr. Bell.

Continued...
SUPERVISORS NAME: Tashima Daniel
LICENSING EVALUATOR NAME: Nancy Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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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Document Has Been Signed on 11/15/2021 02:12 PM - It Cannot Be Edited


Created By: Nancy Diaz On 11/15/2021 at 01:54 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
, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: MISSION VALLEY YMCA - LONGFELLOW ELEMENTARY SCHOOL
FACILITY NUMBER: 376600371

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2021
Section Cited
CCR
101229(a)(1)

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RESPONSIBILITY FOR PROVIDING CARE AND SUPERVISION.
No child(ren) shall be left without the supervision of a teacher at any time...

This requirement was not met as evidenced by:
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DEFICIENCY CORRECTED. Site Supervisor Alex Bell met with all his staff to discuss the importance of providing visual supervision at all times. Rosters were provided to all staff. Staff are to conduct name to face counts, headcounts and name counts when transitioning to another area. A copy of site meeting agenda conducted on 1/1/21 was provided by Mr. Bell today.
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Based on documents received from the facility director and interview conducted with the child involved, it was reported that a child was left unattended and without supervision by a staff in the bathroom on 10/28/21. Facility speculated that the child was left unattended for approximately 5 minutes.
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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.
SUPERVISOR'S NAME:Tashima Daniel
LICENSING EVALUATOR NAME:Nancy Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021


LIC809 (FAS) - (06/04)
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