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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010200607
Report Date: 05/09/2022
Date Signed: 05/26/2022 12:53:23 PM

Document Has Been Signed on 05/26/2022 12:53 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:BERKELEY YMCA HEAD START - SOUTH YMCAFACILITY NUMBER:
010200607
ADMINISTRATOR:CAMERON SCOTTFACILITY TYPE:
850
ADDRESS:2901 CALIFORNIA STREETTELEPHONE:
(510) 848-9092
CITY:BERKELEYSTATE: CAZIP CODE:
94703
CAPACITY: 52TOTAL ENROLLED CHILDREN: 52CENSUS: 24DATE:
05/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Dorian BurnleyTIME COMPLETED:
03:15 PM
NARRATIVE
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This is an amended version of an original report dated on May 6, 2022.

On May 6, 2022 Licensing Program Analysts (LPAs), Melissa Domantay and Indira Loza, conducted an unannounced case management inspection due an Unusual Incident Report received on April 1st, 2022. LPAs met with Director Dorian Burnley, and toured the full facility that is utilized by the Preschool component. LPAs observed 7 staff and 24 children in care. LPAs inspected the Preschool to ensure the Health and Safety of children in care.

During today's inspection LPAs conducted staff interviews. See 809-D for Type A deficiency.

Exit interview conducted. A copy of report and appeal rights provided to Director Dorian Burnley.

Deficiency was cited for a teacher violating a child's personal rights when she pinched them. Although it may or may not have been an accident, the child's personal rights were violated. See 809-D for the deficiency 101223(a)(3) and personal rights.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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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Document Has Been Signed on 05/31/2022 11:18 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/25/2022 07:18 PM


Created By: Indira Loza On 05/09/2022 at 02:21 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: BERKELEY YMCA HEAD START - SOUTH YMCA
FACILITY NUMBER: 010200607

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/12/2022
Section Cited
CCR
101223(a)(3)

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To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation...and mental abuse This requirement was not met as evidenced by staff interviews. This poses an immediate health and safety risk to children in care. It was determined that the teacher pinched the child who was flailing his arms and was attempting
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Facility will conduct a staff meeting and discuss children's Personal Rights will submit minutes of the meeting,and a sign-in sheet of staff who attended. Also, staff must review Personal Rights videos on the CDSS website, and submit a statement from each staff of what they learned from the video.
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to keep the child from hitting the same teacher, and snapping thier fingers in the child's face.
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022


LIC809 (FAS) - (06/04)
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