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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376701523
Report Date: 12/07/2022
Date Signed: 12/07/2022 03:36:23 PM

Document Has Been Signed on 12/07/2022 03:36 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: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: 60CENSUS: 9DATE:
12/07/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Dominique YamsuanTIME COMPLETED:
03:35 PM
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On 12/07/22 at 2:39 p.m., Licensing Program Analyst (LPA), Edgar Campana arrived at the facility to conduct a licensee initiated case management visit for the addition of room 313 to day care license. Upon arrival LPA met with site supervisor, Dominique Yamsuan, and proceeded to tour the facility. There were nine (9) children and two (2) staff present. Facility is within ratio/capacity limitations. Facility plans to operate during the traditional year round 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.

This school-age day care program currently operates in the following classroom: Multipurpose Room (MPR). The number of toilets and sinks is sufficient to accommodate the requested capacity of 60 children. LPA observed required postings posted.

The proposed room addition (room 313) was inspected and measures a total of 661 square feet. A functioning carbon monoxide detector was observed by LPA.

On September 27, 2022, a fire clearance for 60 children (ages 4.9 through 12 years old) was granted for the MPR and room 313.

Room 313 is approved for day care use by facility.

No deficiencies issued during today’s visit. An exit interview was conducted with site supervisor, Dominique Yamsuan. LPA discussed and provided the following to site supervisor: LIC809 Notice of Site Visit and Appeal Rights.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Edgar Campana
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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