414004720-11-17-2021-05-CC-JSAI-C8UT8T-20211117133053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004720
Report Date: 11/17/2021
Date Signed: 11/17/2021 01:31:31 PM

Document Has Been Signed on 11/17/2021 01:31 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	YMCA OF SF-PENINSULA BRANCH-JOHN MUIR ELEM.ASP		FACILITY NUMBER:	414004720
ADMINISTRATOR:	SENORES, ANNE		FACILITY TYPE:	840
ADDRESS:	130 CAMBRIDGE LANE		TELEPHONE:	(670) 286-9622
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY: 75	TOTAL ENROLLED CHILDREN: 75	CENSUS: 0	DATE:	11/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Director Oscar Rodriguez		TIME COMPLETED:	01:50 PM

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Licensing Program Analyst (LPA) Jyoti Saini met with Director Oscar Rodriguez for an unannounced Annual Random Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the director. There were no children in care. The facility operates Monday - Friday from 1:00pm to 6:00pm. LPA and Site Supervisor inspected the day care areas for health and safety hazards. This facility is operating in room # 1-20 on a functioning school site of John Muir Elementary School. There are no bodies of water, firearms, or weapons on the premises. The center is in good condition with proper temperature and ventilation and is free of any hazards. All furniture is in good repair. The Center has age-appropriate toys and equipment. A first aid kit and a first aid backpack are available. The outdoor play area is fenced for supervision. The play structure is age-appropriate and in good condition. There are separate bathrooms for boys and girls. The bathrooms appear to be safe, sanitary, and free of any hazardous items. There is drinking water readily available for children. The program provides daily snacks. The classroom has appropriate postings. The last Emergency Drill was conducted on 11/15/2021 and is properly logged.

LPA reviewed sign-in and out sheet. The center has a complete record of sign-in/out sheets by an authorized pick up person. The room has a working smoke and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone available. There are sinks for children located in work room and bathrooms for children to use. Isolation area for ill children is school office.

LPA reviewed Six children files and were complete. All children have a record of emergency identification information on file. Staff records reviewed were complete. All staff has a criminal record clearance on file. The staff has a current Pediatric First Aid/CPR certificate on file. The staff has taken Mandated Reporter training.

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SUPERVISORS NAME: Alma Malig
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: YMCA OF SF-PENINSULA BRANCH-JOHN MUIR ELEM.ASP	FACILITY NUMBER: 414004720
	VISIT DATE: 11/17/2021

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During inspection,

This facility provides Incidental Medical Services – IMS. LPA reviewed storage area for medication and equipment/supplies, and reviewed forms that will be used. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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

For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Section 101226. When any IMS is provided, a plan for providing IMS must be submitted to the Department.

• Site Director was reminded as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.662.

• Site Director was reminded about Mandated Reporter Training available on the CCLD website. Training must be completed every two years. (Websites: www.ccld.ca.gov or www.mandatedreporterca.com)

• Site Director was reminded about the Provider Information Notices (PINs) on the CCLD website.

>No deficiencies were cited today under Title 22 Division 12 of the Ca. Code of Regulations.

> This report must be available in the facility for public review. Notice of site visit shall be posted for 30 days from today's visit.

SUPERVISORS NAME: Alma Malig
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC809 (FAS) - (06/04)

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