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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013417825
Report Date: 06/22/2023
Date Signed: 06/22/2023 10:28:00 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2023 and conducted by Evaluator Indira Loza
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20230518084436
FACILITY NAME:BERKELEY YMCA EHS - VERA CASEYFACILITY NUMBER:
013417825
ADMINISTRATOR:GLORIA CROSS-BROOKSFACILITY TYPE:
830
ADDRESS:2246 MARTIN LUTHER KING JR WAYTELEPHONE:
(510) 542-2146
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY:26CENSUS: 19DATE:
06/22/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kathy NguyenTIME COMPLETED:
10:36 AM
ALLEGATION(S):
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Personal Rights - Staff did not make prompt arrangements for obtaining medical treatment for child in care
INVESTIGATION FINDINGS:
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On June 22, 2023 at 9:29am Licensing Program Analyst (LPA) Indira Loza met with Site Supervisor Kathy Nguyen to continue the investigation for the above allegation. Present during the inspection were 19 children and 7 fingerprint cleared staff. During the visit LPA and LPM toured the facility, interviewed staff, and collected additional documents relavent to the complaint.

During the course of the investigation, the facility was inspected for a health and safety check, collected documents regarding the complaint, interviewed staff, and parents. Based on record review and interviews, it has been determined that the child was recognized as having asthma symptoms but was not given medication in a timely manner. Therefore, the preponderance of evidence standard has been met and this allegation is Substantiated, California Code of Regulations, Title 22, Division 12 is being cited on 9099-D page.

*********************See LIC 9099-C for report continuance********************
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 02-CC-20230518084436
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 EHS - VERA CASEY
FACILITY NUMBER: 013417825
VISIT DATE: 06/22/2023
NARRATIVE
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Currently enrolled and newly enrolled children must have an Acknowledgement of Receipt of Licensing Report (LIC9224) signed by the children's parent in each child's file, and must remain in the files for 12 months. Additionally, the report and LIC9224 must be provided to any child enrolled in the program within 12 months of the issuance of this citation.

Exit Interview and Report Reviewed with Site Supervisor Kathy Nguyen.
Notice of Site visit and Appeal Rights provided.
Report and Notice of Site must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 02-CC-20230518084436
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 EHS - VERA CASEY
FACILITY NUMBER: 013417825
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2023
Section Cited
CCR
101223(a)(3)
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Personal Rights - (a) The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, ... This requirement was not met as evidenced by:
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The Director shall submit a plan detailing on how to best handle medication administration when a child needs their medication in a timely manner.
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Based on Interview and record review it was determined that the staff did not administer the child's medication in a timely manner; which can be in immediate risk to the health, safety, and personal rights to children in care.
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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.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3