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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701523
Report Date: 07/18/2022
Date Signed: 07/18/2022 10:34:47 AM

Document Has Been Signed on 07/18/2022 10:34 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:SOUTH BAY FAMILY YMCA - JEFFERS ELEMENTARYFACILITY NUMBER:
376701523
ADMINISTRATOR:VALERIA RINCONFACILITY TYPE:
840
ADDRESS:1145 CAMINO PRADOTELEPHONE:
(619) 421-9622
CITY:CHULA VISTASTATE: CAZIP CODE:
91913
CAPACITY: 60TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/18/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:23 AM
MET WITH:Lucelyna GodwinTIME COMPLETED:
10:50 AM
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On 07/18/22 8:23 a.m., Licensing Program Analyst (LPA), Rajani Goudreau arrived at the facility to conduct an announced pre-licensing inspection. Upon arrival LPA, met with Association Program Specialist, Lucelyna Godwin, Department Head, Miriam Martinez, Director, Valeria Rinconand proceeded to tour the facility. The facility is requested a capacity of 60 children, serving ages 4.9 through 12 years old. This school-age program will operate at Fahari L. Jeffers Elementary school in the multipurpose (MPR) room located in the front of the school on the right hand side. Facility plans to operate during the traditional year around school schedule: Monday through Friday from 6:00 a.m. to 8:30 a.m., Monday through Thursday from 2:30 p.m. through 6:00 p.m., and Friday from 1:00 p.m. to 6:00 p.m.

Facility is exempt from square footage, toilet, isolation space, outdoor activity space, and fencing requirements, per, H&S 1596.806. The MPR room is equipped with age appropriate furniture; including tables, chairs, bookshelves, and other materials for the children’s use. There is a functioning carbon monoxide detector and a first aid kit with required supplies located in the MPR room. During the inspection, no bodies of water were observed on the premises of the property. Disinfectants, cleaning solutions, medication and other hazardous items were observed to be made inaccessible. Drinking water is available both indoors and outdoors through the use of refillable water containers and cups provided by the facility. Snacks will be provided by the program. Parents will be utilizing digital sign in and sign out. Required documents were observed to be posted. The facility will be utilizing boy and girl restrooms attached to the outside of the MPR on the right hand side. All toilets and hand washing facilities were observed to be in safe and sanitary operating condition. The floors in the facility were observed to be clean and safe, per observation. See LIC809-C continuation page...
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Rajani Goudreau
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: SOUTH BAY FAMILY YMCA - JEFFERS ELEMENTARY
FACILITY NUMBER: 376701523
VISIT DATE: 07/18/2022
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Children are to be escorted and supervised by staff to and from the restrooms. The isolation area and restroom is located in the nurse’s office. The outdoor activity space is located adjacent to the MPR; including a grass area, playground structure, blacktop area, and bench area. The outdoor space was inspected and includes a play structure, which is safe and age appropriate, sufficient material for cushioning through the use of cushioning grass turf. Shade is available for the children by the use of building awnings. The surface of the outdoor activity space was observed to be free of hazards. Discussed proper supervision and placement of staff during outdoor activities to ensure the safety of the children at all times.

A fire clearance for 60 children; ages 4.9 through 12 years old in the MPR room was granted on July 06, 2022.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A 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. LPA and Applicant discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov.

Facility representative 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, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Rajani Goudreau
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
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
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: SOUTH BAY FAMILY YMCA - JEFFERS ELEMENTARY
FACILITY NUMBER: 376701523
VISIT DATE: 07/18/2022
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

Initial water lead testing results shall be received and posted within 180 days of licensure. LPA provided and discussed the following: PIN 21-21-CCP, External Water Sampler Self-Certification Form (LIC 9275), Child Care Center Sampling Checklist Form (LIC 9276).



To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and reports were reviewed with the facility representative, Lucelyna Godwin. After final file review, a license for 60 children; ages 4.9 through 12 years old will be granted. Once the license is granted, the license will be mailed. Once received the license shall be posted in a prominent location.

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: Rajani Goudreau
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC809 (FAS) - (06/04)
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