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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701126
Report Date: 09/28/2023
Date Signed: 09/29/2023 08:05:04 AM

Document Has Been Signed on 09/29/2023 08:05 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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:YMCA - MCKINLEY ELEMENTARYFACILITY NUMBER:
376701126
ADMINISTRATOR:SHANYCE SAMUELUFACILITY TYPE:
840
ADDRESS:3045 FELTON STREETTELEPHONE:
(619) 282-7694
CITY:SAN DIEGOSTATE: CAZIP CODE:
92104
CAPACITY: 120TOTAL ENROLLED CHILDREN: 120CENSUS: 89DATE:
09/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Shanyce SamueluTIME COMPLETED:
03:30 PM
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On 9/28/2023 at 2:15 p.m., Licensing Program Analyst (LPA) Cindy Meier conducted an unannounced Case Management inspection regarding an incident that occurred on 9/6/2023. Upon arrival, LPA advised Site Supervisor, Shanyce Samuelu the purpose of the inspection and was led on a tour of the facility. Present during the inspection were 89 children and ten (10) staff.

On 9/21/2023 the facility self reported an Unusual Incident where according to staff witnesses, child (C1) wandered off when the staff and other children were transitioning from using the bathroom. C1 was left unattended for approximately five to ten (5-10) minutes. C1 did not leave the campus.

During the inspection the LPA interviewed site supervisor, staff (S1) and C1.

No deficiencies issued during today's visit.

Exit interview conducted and report was reviewed with Site Supervisor, Shanyce Samuelu. A copy of this report, along with Appeal Rights (LIC9058), were provided. A Notice of Site Visit was given and must remain posted for 30 days. LPA observed that the Notice of Site Visit was posted during the inspection.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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