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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422419
Report Date: 10/27/2021
Date Signed: 10/27/2021 02:13:06 PM

Document Has Been Signed on 10/27/2021 02:13 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:YMCA OF THE EAST BAY Y-KIDS PATTERSONFACILITY NUMBER:
013422419
ADMINISTRATOR:KAY, MORIAHFACILITY TYPE:
840
ADDRESS:35521 CABRILLO DR.TELEPHONE:
(925) 808-5287
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Moriah WaltonTIME COMPLETED:
02:20 PM
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On October 27 2021 at approximately 9:30am, LPA Haderer arrived unannounced for an annual inspection for compliance to Health and Safety. The new CARE tool was used for the inspection. Present for the inspection was the site director Moriah Walton, no others had arrived yet. During the inspection, two additional staff members and 10 children in care (Kindergarten to 4th grade). The center currently operates from 11:30am to 6:00PM.

The child care center operates in a large portable room on the campus of Patterson Elementary School. The children use the school yard and playground, all is in safe condition and free from sharp, loose or pointed parts and the areas around or under high climbing equipment has appropriate cushioned material that absorbs a fall. Access to drinking water is available and teachers are always present.



The facility has 2 fully charged 3A40BC fire extinguishers, one mounted next to each door in the classroom. The last annual inspection was done 10/14/2021. Fremont Fire Department conducts fire inspections. The carbon monoxide detector was tested and functioning. Heating and ventilation in the classroom is acceptable.

The facility is clean and well organized with ample age appropriate furnishings and equipment. Surfaces including floors and counter tops are clean and toxic free. Hazardous items/toxins are kept in a cabinet in the staff restroom out of the access of children. There are no bodies of water accessible to children in care. Children bring their own food from home, the center provides snacks.

Children use the single bathroom in the classroom and if needed, use the school bathrooms on campus. There are enough towels and soap supplies. The staff have separate adult bathroom located in the classroom.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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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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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: YMCA OF THE EAST BAY Y-KIDS PATTERSON
FACILITY NUMBER: 013422419
VISIT DATE: 10/27/2021
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Disaster drills are conducted at least once every six months, the last drill was conducted September 14, 2021

The sign in/out sheets were reviewed and are accurate. Classrooms have trash cans with tight fitting cover for the disposal of solid waste. There is one child that requires incidental medication (EpiPen’s), medications were not expired and signed parent authorization forms were in the file.

Children's records were reviewed: LPA requested the children's facility roster, roster not available. See LIC809D for details. All files selected were complete and up to date.

Staff files were reviewed. Opening and closing staff have current CPR and first aid training. All staff subjected to criminal review have been cleared and associated to the facility. Some staff files were missing proof of flu shot, it is time for flu shots now and being scheduled.

All documents required to be posted were appropriately posted on the walls: License; Emergency Disaster Plan; Earthquake Preparedness checklist; Notification of Parents Rights; Personal rights; Child seatbelt laws; menus; daily activity schedules. One waiver for the facility was posted regarding outdoor shared space with the elementary school.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Site Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: YMCA OF THE EAST BAY Y-KIDS PATTERSON
FACILITY NUMBER: 013422419
VISIT DATE: 10/27/2021
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A deficiency was issued today, see LIC809D

A notice of site visit was given and must remain posted for 30 days.



Exit interview conducted and report was reviewed with the Site Director Moriah Walton.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2021 02:13 PM - It Cannot Be Edited


Created By: Russell Haderer On 10/27/2021 at 01:26 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: YMCA OF THE EAST BAY Y-KIDS PATTERSON
FACILITY NUMBER: 013422419

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1586.841

1596.841 Current roster of children provided care in facility required
Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2021
Plan of Correction
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Licensee will complete a current LIC9040 Roster and keep an updated record of this roster going forward. A roster will also be available for the past three years.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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