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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211396
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:47:15 PM

Document Has Been Signed on 11/09/2022 02:47 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:YMCA OF THE EAST BAY Y-KIDS DURHAMFACILITY NUMBER:
010211396
ADMINISTRATOR:SHAFFERS, NELDAFACILITY TYPE:
840
ADDRESS:40292 LESLIE STREETTELEPHONE:
(510) 683-9107
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 41TOTAL ENROLLED CHILDREN: 41CENSUS: 28DATE:
11/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Tonya RansomTIME COMPLETED:
02:55 PM
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On November 9th, 2022 @ 1:55pm, Licensing Program Analyst (LPA) April Wright met with Head Teacher Tony Ransom for an UNANNOUNCED POC INSPECTION. Present for this visit was 28 preschool/school age children, and two fingerprint cleared staff members Shamim Hameed and Adrielle Barrera.

LPA advised assistant director of the nature of the visit. LPA Wright cleared the deficiency which was cited on 11/2/22 for Child's Records/Missing LIC627 Consent for Emergency Medical Treatment form (C3).

LPA reminded Assistant Director to have parents/guardians complete all forms prior to enrollment into the center and confirm forms are completed.

LPA Wright provided licensee a clearance letter for the child's records citation.

There are no deficiencies cited today. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted Head Teacher Tonya Ransom.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: April Wright
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2022
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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