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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420963
Report Date: 01/10/2023
Date Signed: 01/10/2023 02:28:58 PM

Document Has Been Signed on 01/10/2023 02:28 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 - EMERYVILLE MARINAFACILITY NUMBER:
013420963
ADMINISTRATOR:WILLIAMS, ROCHELLE LA'RUEFACILITY TYPE:
850
ADDRESS:1275 - 61ST STTELEPHONE:
(510) 601-8674
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 43DATE:
01/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:ROCHELLE WILLIAMSTIME COMPLETED:
02:45 PM
NARRATIVE
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1:00PM- Licensing Program Analyst Tasha Alexander met with Center director Rochelle Williams for an UNANNOUNCED CASE MANAGEMENT inspection. Today there are 43 children present along with 16 staff. The purpose of this inspection is to follow up on an unusual incident report regarding a child left without supervision for a short time, and lead testing results exceeded 5.5 ppb.

LPA toured the facility and reviewed documents. The facility has removed the outlet, and LPA verified by inspecting the location. The facility has completed an active supervision training with all staff, and changed protocol to now have all doors of the multipurpose room closed when occupied to prevent children from leaving the area without supervision. If the doors need to be opened, there shall be a staff member positioned at the door to also prevent children from leaving the area.

See 809-D for deficiencies being cited today.

An exit interview was conducted with Ms. Williams and a copy of the report and appeal rights were provided. A notice of Site visit was given to Licensee, and Licensee was reminded that it needs to be posted for 30 days

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2023
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 01/10/2023 02:28 PM - It Cannot Be Edited


Created By: Tasha Hackett-Alexander On 01/10/2023 at 01:50 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: BERKELEY YMCA HEAD START - EMERYVILLE MARINA
FACILITY NUMBER: 013420963

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2023
Section Cited
HSC
101700.3(b)(1)

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101700.3(b)(1) Lead Testing Written Directive A result with values of 5.5 ppb or greater shall be deemed an Action Level Exceedance

This requirement has not been met as evidenced by record review. The licensee did not comply with the section cited above which poses a potential Health and Safety risk to persons in care.
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The facility has removed the outlet.
Type B
01/11/2023
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs.

(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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The facility has provided staff training for active supervision and changed protocol to have all doors to the multipurpose room closed to prevent children from leaving the area. Should the doors be open, a staff member will be stationed at the door to prevent children from leaving the area.
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This requirement has not been met as evidenced by the unusual incident submitted by the facility reporting that a child was left without supervision for a shor period. This poses an immediate risk to the health and safety of 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.
SUPERVISOR'S NAME:Loretta Dyson
LICENSING EVALUATOR NAME:Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023


LIC809 (FAS) - (06/04)
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