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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191608844
Report Date: 10/20/2022
Date Signed: 10/20/2022 04:59:52 PM

Document Has Been Signed on 10/20/2022 04:59 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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:YMCA GLB - WEINGART-LAKEWOOD - GOMPERS SITEFACILITY NUMBER:
191608844
ADMINISTRATOR:EVELYN GARIBAYFACILITY TYPE:
840
ADDRESS:5206 BRIERCRESTTELEPHONE:
(562) 925-6493
CITY:LAKEWWODSTATE: CAZIP CODE:
90713
CAPACITY: 56TOTAL ENROLLED CHILDREN: 93CENSUS: 33DATE:
10/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Director, Evelyn GaribayTIME COMPLETED:
05:15 PM
NARRATIVE
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On October 20, 2022 at 1:30 pm, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced inspection at the facility noted above and met with Director, Evelyn Garibay. The purpose of the inspection was to follow-up on an incident that occurred at the facility.

An incident was brought to the Department's attention that a child (C1) had fallen and sustained an injury while in care. During the inspection, LPA conducted an interview with the Director who confirmed that the incident had resulted in C1 sustaining an injury that required medical treatment. Director also confirmed that the incident/injury was not reported to the Department.

LPA was informed that C1 had accidentally fallen while inside the cafeteria. Per Director, C1 was provided with an ice pack, C1's parent was immediately contacted, and an "Ouch" report was provided to the parent upon pick-up. The Director stated that C1 was picked up from the facility by their parent and was later seen by a doctor. Per C1's parent, C1 sustained a fracture from the incident. LPA advised the Director on Reporting Requirements per Title 22 regulations. LPA also obtained copies of pertinent documents.

During the inspection at 3:45 pm, LPA observed a child (C2) come inside the cafeteria while all staff and the other children were outside. LPA observed the child attempt to sit down at a bench/table inside the cafeteria but accidentally fell on the floor. LPA walked up to the child who began crying and apologizing for spilling the tray of snacks (cups of fruit and animal crackers) on the floor. Per C2, C2 was not injured but was clearly upset about the incident. LPA looked around and did not observe any staff present. LPA walked outside and notified staff (S1) of the incident. S1 came into the cafeteria and began talking to C1.

During today's inspection, deficiencies were cited for failure to report the incident/injury that occurred at the facility on 10/7/2022 and for the lack of supervision that LPA had observed during the inspection.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Monique Ayala
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: YMCA GLB - WEINGART-LAKEWOOD - GOMPERS SITE
FACILITY NUMBER: 191608844
VISIT DATE: 10/20/2022
NARRATIVE
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A Notice of Site Visit (LIC ) was provided and must remain posted for 30 days.

An exit interview was conducted and a copy of the report was reviewed with Director, Evelyn Garibay.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Monique Ayala
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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Document Has Been Signed on 10/20/2022 04:59 PM - It Cannot Be Edited


Created By: Monique Ayala On 10/20/2022 at 04:10 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: YMCA GLB - WEINGART-LAKEWOOD - GOMPERS SITE
FACILITY NUMBER: 191608844

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2022
Section Cited
CCR
101212(d)

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101212(d) Reporting Requirements. Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. ...
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The facility will complete an Unusual Incident/Injury Report (LIC 627) for the incident/injury and submit the completed LIC 627 to the Monterey Park Child Care Regional Office by fax, mail, e-mail or drop-off by October 28th.
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This requirement is not met as evidenced by:
Based on interview and record review, the facility did not report an incident to the Department that resulted in a child sustaining an injury requiring medical treatment which posed a potential health, safety or personal rights risk to persons in care.
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Type B
11/21/2022
Section Cited
CCR101229(a)(1)

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101229(a)(1) Responsibility for Providing Care and Supervision. 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 will conduct a training with all staff on care and supervision per Title 22 regulations, and will submit a copy of a sign-in sheet and presented material to LPA via e-mail by November 21st.
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This requirement is not met as evidenced by:
Based on observation, LPA witnessed a child accidentally fall inside the cafeteria while no staff were present or providing visual supervision which posed a potential health, safety or personal rights risk to persons 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:Valarie Cook
LICENSING EVALUATOR NAME:Monique Ayala
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022


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