414004720-10-4-2023-05-CC-CQUO-CWAVMS-20231004163402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004720
Report Date: 10/04/2023
Date Signed: 10/04/2023 04:34:09 PM

Document Has Been Signed on 10/04/2023 04:34 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
SAN BRUNO CC RO, 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: 41	CENSUS: 34	DATE:	10/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Jam Hornesby		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On October 4, 2023, at approximately 1:40pm, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with site coordinator, Jam Hornesby, and explained the purpose of the visit. YMCA after school program operates at John Muir Elementary School and is licensed to operate in Classrooms #1 to 20, cafeteria, library, inner courtyard, K1 Playground, and main playground. Present during LPA's visit included 3 staff with 34 children. Children enrolled in program attend elementary school. Hours of operation are Monday, Tuesday, Thursday and Friday 2:00pm to 6:00pm and Wednesday 1:00p to 6:00pm. With site coordinator, LPA inspected day care areas currently in use, for health and safety hazards. YMCA is currently operating in school cafeteria, library, and K1 playground. Main room currently used is cafeteria while the library is utilized for homework purposes only. LPA observed YMCA areas in use to be equipped with appropriate furniture and equipment. There are a variety of games, books, and materials that are age appropriate. LPA observed cafeteria to have a fire extinguisher, smoke alarm system installed and implemented. Cafeteria is equipped with a working smoke detector and carbon monoxide detector. LPA tested carbon monoxide detector located in cafeteria, next to stage stairs, which was observed to be working. Cafeteria and library are ventilated with appropriate temperature. Children's belongings are placed in the cafeteria. LPA observed poisons, chemicals, and cleaning solutions to be placed in YMCA staff area that children do not have access to. (Continue Report on Page 2...)

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 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: 10/04/2023

NARRATIVE

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YMCA program utilizes school district bathroom. Bathrooms for children allow for individual privacy. LPA observed bathrooms to be in proper working condition, equipped with appropriate sanitation products. Bathrooms have a garbage bin that is disposed of daily by school district janitorial services.

Outdoor area currently in use is K1 playground. LPA observed playground to have a play structure with resilient padding underneath. Outdoor area is entirely enclosed and fenced that YMCA program has exclusive use of. LPA did not observe any pools, spas or bodies of water on site.

YMCA program provides afternoon snacks that is provided by the school district. Children have access to water indoors and outdoors with children's individual water bottles that can be refilled on site through a filtered water station located in cafeteria.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care
Centers (CCCs) constructed before January 1, 2010, to test their water (used for
drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

LPA referred licensee to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

Per site coordinator, YMCA is scheduling to test filtered water station located in cafeteria.

Children are signed into after school program by YMCA staff. Children's authorized representatives sign children out with written signatures. Required licensing documentation is properly posted and available for review in the cafeteria.

LPA reviewed facility records that included 6 random children's files and 3 staff member's files (whom were present during inspection) which were complete. Children's files have record of emergency identification information on file. Staff have required immunizations on file. 2 of the 3 staff members present have a current CPR/First Aid certification.
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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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
SAN BRUNO CC RO, 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: 10/04/2023

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Site coordinator was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

Site coordinator was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at
www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/

Facility representative was informed of the MyChildCarePlan.org website; a
consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Facility was cited a Type B citation for not completing lead testing requirements by due date. Appeal Rights were provided. A POC was discussed.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the site coordinator, Jam Hornesby.

SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/04/2023 04:34 PM - It Cannot Be Edited

Created By: Catrina Quimbo On 10/04/2023 at 03:53 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: YMCA OF SF-PENINSULA BRANCH-JOHN MUIR ELEM.ASP	FACILITY NUMBER: 414004720
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.16(a)(1)

Lead Testing

(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/06/2023
	Plan of Correction
1 2 3 4	Program has to schedule to test water fixtures used for water consumption for lead levels. Completed LIC9275, LIC9276, LIC999 and results of lead levels to be submitted to LPA no later than POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Marie Rodriguez

LICENSING EVALUATOR NAME:

Catrina Quimbo

LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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