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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494850
Report Date: 06/19/2025
Date Signed: 06/19/2025 05:03:15 PM

Document Has Been Signed on 06/19/2025 05:03 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:BURBANK YMCA HORACE MANN CHILDRENS CENTERFACILITY NUMBER:
197494850
ADMINISTRATOR/
DIRECTOR:		DIERIK GONZALEZFACILITY TYPE:
830
ADDRESS:3401 SCOTT ROADTELEPHONE:
(818) 729-1650
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 7DATE:
06/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Director / Diane ConnellTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 06/19/25, at 1:45PM, Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced Case Management Visit to this facility. Upon arrival, LPA met with Director / Diane Connell, who guided LPA on a tour of the facility. There were 7 children with 2 staff observed present in the Toddler Program. LPA explained the purpose of today's visit is to follow-up on an incident that was reported to Community Care Licensing (CCL) on 06/17/25.

The incident that occurred on 06/16/25, was reported to the Department on 06/17/25, via Unusual Incident/Injury Report. The facility reported the Unusual Incident to the Department within the required 24 hours of occurrence.

Information reported to the Department indicated that teacher-to-child ratio may or may not have been a factor in the incident involving Child 1. During the course of the investigation, LPA conducted an interview of the Director and obtained Children's / Staff rosters and other pertinent information regarding this incident.

On 6/16/25, at 8:50AM, Child 1 was dropped off by their parent in Room 1 (Toddler Program). At the time of drop-off, there was only one teacher present (Staff 1) in the classroom, supervising six children. With the addition of Child 1, the total number of children increased to seven, placing the classroom out of compliance with the required teacher-to-child ratio for the toddler age group. Staff 2 arrived at 8:52AM, at which point the classroom returned to compliance. Room 1 was out of ratio for approximately two minutes.

The following deficiency listed on the attached deficiency page is being cited in accordance with California Code of Regulations Title 22.
(Please see LIC 809C for additional information)
NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: BURBANK YMCA HORACE MANN CHILDRENS CENTER
FACILITY NUMBER: 197494850
VISIT DATE: 06/19/2025
NARRATIVE
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Upon receipt of this report, the Licensee shall post the Notice of Site Visit and any Licensing report
documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive
days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this
report shall be provided to the parent/guardian of children currently enrolled by the next business day or
immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly
enrolled children for the next 12 months (1 year). The Acknowledgement of Receipt (LIC 9224 form must be
maintained in each child ’s file immediately upon receipt from parent. Licensee was provided with a copy of
the Acknowledgement of Receipt of Licensing Reports (LIC 9224) Form during this visit.


The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative.

An exit interview was conducted with Director / Diane Connell and Appeals Rights provided.
NAME OF LICENSING PROGRAM MANAGER: Rita Ramos
NAME OF LICENSING PROGRAM ANALYST: Joe Katrdzhyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/19/2025 05:03 PM - It Cannot Be Edited


Created By: Joe Katrdzhyan On 06/19/2025 at 03:52 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: BURBANK YMCA HORACE MANN CHILDRENS CENTER
FACILITY NUMBER: 197494850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2025
Section Cited
HSC
1596.955(a)(3)

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Child day care centers serving preschool age children; optional program; departmental guidelines and regulations.
A ratio of six children to each teacher is maintained for all children in attendance at the toddler program. This requirement was not being met as evidenced by:
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The Director will submit a written plan of correction (POC) indicating how the center will maintain ratios and ensure compliance at all times. The POC must be submitted to CCL by the POC due date of 6/20/25.
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On 6/16/25, at 8:50AM, Child 1 was dropped off by their parent in Room 1 (Toddler Program). At the time of drop-off, there was only one teacher present (Staff 1) in the classroom, supervising six children. With the addition of Child 1, the total number of children increased to seven, placing the classroom out of compliance with the required teacher-to-child ratio for the toddler age group. Staff 2 arrived at 8:52AM, at which point the classroom returned to compliance. Room 1 was out of ratio for approximately two minutes.
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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.
Rita Ramos
NAME OF LICENSING PROGRAM MANAGER:
Joe Katrdzhyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2025


LIC809 (FAS) - (06/04)
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