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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430709586
Report Date: 01/23/2025
Date Signed: 01/23/2025 04:46:02 PM

Document Has Been Signed on 01/23/2025 04:46 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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:YMCA-HACIENDA VALLEY VIEWFACILITY NUMBER:
430709586
ADMINISTRATOR/
DIRECTOR:		QUE-HEATH,ROYFACILITY TYPE:
840
ADDRESS:1290 KIMBERLY DRIVETELEPHONE:
(408) 978-1156
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 105TOTAL ENROLLED CHILDREN: 105CENSUS: 58DATE:
01/23/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Roy Que-Heath & Audrey VossTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jennifer "Jen" Beehler conducted an unannounced visit to continue the Annual Inspection that began on 01/07/2025. Upon arrival LPA was greeted by site Director Roy Que-Heath and Facility Administrator Audrey Voss and provided a tour of the interior and exterior of the facility. There were 58 children in care and 4 teachers, 1 director and facility representative present which is compliant with ratio requirements.

LPA reviewed fire/disaster drill log during today’s inspection. The last fire/disaster drill was conducted on 01/10/2025, which is compliant with the six month requirement for facilities. The Director states that he does have a child in care who require Incidental Medical Services. LPA observed medication to be kept in an upper locked cabinet in the kitchen area. The medication was labeled and kept with the instructions to administer.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. 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/.

Indoor areas of the facility were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via water dispensers and reusable cups from home, labeled with the children’s names.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: YMCA-HACIENDA VALLEY VIEW
FACILITY NUMBER: 430709586
VISIT DATE: 01/23/2025
NARRATIVE
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Staff and children’s bathrooms are clean, sanitary, and operable. Cleaning and maintenance for the facility is conducted by an outside service and is completed in the evenings after all day care children have left the premises. The Director states that there are no weapons or firearms on the premises.

The outdoor area of the facility was inspected and observed to be fenced in. LPA observed play equipment was in good condition, age-appropriate, and has sufficient resilient materials (astro-turf) to absorb falls. No outdoor bodies of water were observed during today’s inspection. Shaded rest area is provided by canopy and trees.

Food is provided by the facility and is stored, prepared, and served in a safe and healthful manner to the children. Facility provides PM snack to children. Menu is in writing and posted at least one week in advance, accessible to authorized representatives. The kitchen and storage area is clean and free of litter and rubbish. Equipment necessary for the storage, preparation and service of food is well maintained, clean, and sanitized after each use.

5 children’s files (school-age) were reviewed during today’s inspection for the following records: Physician’s Report (LIC701), Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Signed Admission Agreement, and Immunization Records (PM286). 5 staff files (1 director/3 teacher/1 aide) were reviewed for the following records: Transcripts/Verification of Experience, Health Screening Report (LIC503), Employee Rights (LIC9052), Criminal Record Statement (LIC508), Statement Acknowledging Requirement to report Child Abuse (LIC9108), Mandated Reporter Training Certificate, Tuberculosis (TB) Clearance, and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza or statement declining influenza. LPA observed two files missing LIC503 and a negative TB test completed within one year of employment or sooner. There is at least one staff member present with current CPR/First-Aid that expires 06/2025. The Director has current Mandated Reporter Training that expires on 03/01/2025. LPA reminded Director that the Mandated Reporter Training must be renewed by all staff every 2 years.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: YMCA-HACIENDA VALLEY VIEW
FACILITY NUMBER: 430709586
VISIT DATE: 01/23/2025
NARRATIVE
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The Director understands that the site director shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times. LPA reminded Director that there shall be at least one person with valid CPR and First-Aid certifications on site at all times or present during off site activities, such as field trips.

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. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).
LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information. Facility representative provided a copy of the lead testing report from ProTech dated 02/10/2023 which stated all water facilities passed.

Due to today's inspection, Type B citations were issued, more details are included in the attached LIC809-D. Exit interview conducted with Director, Roy Que-Heath and Facility Representative, Audrey Voss, report reviewed and provided. NOTICE OF SITE VISIT PROVIDED AND MUST REMAIN POSTED FOR 30 DAYS.

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.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 04:46 PM - It Cannot Be Edited


Created By: Jennifer Beehler On 01/23/2025 at 04:29 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: YMCA-HACIENDA VALLEY VIEW
FACILITY NUMBER: 430709586

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Director will provide photographic proof of Health Screening for two employees.
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Director will provide photographic proof of Negative TB test for two employees.
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:Joel Segura
LICENSING EVALUATOR NAME:Jennifer Beehler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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