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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561709990
Report Date: 06/17/2026
Date Signed: 06/17/2026 10:09:44 AM

Document Has Been Signed on 06/17/2026 10:09 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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:SIMI VALLEY FAMILY YMCA - HOLLOW HILLSFACILITY NUMBER:
561709990
ADMINISTRATOR/
DIRECTOR:		KAREENA HADAPFACILITY TYPE:
840
ADDRESS:828 GIBSONTELEPHONE:
(805) 527-5730
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 0DATE:
06/17/2026
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Kareena HadapTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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On 6/17/2026 at 9:45AM, Licensing Program Analyst (LPA) Seena Parsapour conducted an announced Case Management – Deficiencies inspection at the abovementioned Child Care Center (CCC). LPA met with Senior Program Director Valerie Ross and explained the nature & purpose of the inspection, which is to address reporting requirements for incidents that occur at the CCC. LPA notes that today’s visit occurred at an offsite location (Yarrow Family YMCA main office; 31105 E Thousand Oaks Blvd, Westlake Village, CA 91362) as this CCC is closed for the summer beginning 06/08/2026 through 08/10/2026. LPA notes that Chief Operating Officer Jamie Gonzalez was present during today's inspection. No children are currently in care. During the initial 10-day visit on 4/23/2026 regarding Complaint Control Number 17-CC-20260414122039, LPA Parsapour observed construction taking place adjacent to the CCC classroom. LPA observed displaced soil in the grassed area, with a cone & caution tape blocking the area off for safety. During interview with LPA, Senior Program Director stated that a burst water pipe occurred some time ago, and repairs were being coordinated by Hollow Hills Elementary School leadership. During the discussion, Senior Program Director acknowledged they were not aware such an issue should be reported to Licensing, and understood that moving forward, all unusual incidents should be reported to CCLD including physical plant issues. LPA Parsapour discussed Unusual Incident reporting requirements with Director as well and confirmed their understanding. LPA Parsapour asked that the incident be retroactively reported to the Department, and Director as well as Senior Program Director agreed with this request. The following day, 4/24/2026, Santa Barbara Regional Office (SBRO) received an email from Senior Program Director with a completed LIC624 – Unusual Incident/Injury Report, pertaining to this incident. (Cont. 809-C, Page 2)
NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Seena Parsapour
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: SIMI VALLEY FAMILY YMCA - HOLLOW HILLS
FACILITY NUMBER: 561709990
VISIT DATE: 06/17/2026
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Additionally, through the course of the aforementioned complaint investigation, LPA Parsapour became aware - through records review and interviews – of an incident which occurred in November 2024 where C1 brought a sharp object to the CCC. Records review revealed the incident was not timely reported to CCLD. A Technical Violation (TV) was issued during today’s inspection regarding reporting requirements.

No deficiencies were cited during today’s inspection. A notice of site visit was given to Senior Program Director and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Appeal Rights were provided to Director. Exit interview conducted and report was reviewed with Senior Program Director Valerie Ross.

NAME OF LICENSING PROGRAM MANAGER: Maria Mueller
NAME OF LICENSING PROGRAM ANALYST: Seena Parsapour
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC809 (FAS) - (06/04)
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