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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300611755
Report Date: 04/14/2021
Date Signed: 04/14/2021 05:22:18 PM

Document Has Been Signed on 04/14/2021 05:22 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:CAPISTRANO BEACH CITIES YMCA- PALISADESFACILITY NUMBER:
300611755
ADMINISTRATOR:FAULS-RIVAS, TYLERFACILITY TYPE:
840
ADDRESS:26462 VIA SACRAMENTOTELEPHONE:
(949) 496-1627
CITY:CAPISTRANO BEACHSTATE: CAZIP CODE:
92624
CAPACITY: 90TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
04/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Tyler Fauls-Rivas.TIME COMPLETED:
04:20 PM
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Tele-Inspection- COVID-19 State of Emergency

Licensing Program Analyst (LPA) Hawkins conducted a tele-visit for the purpose of amending a report previously generated. LPA met with Director Tyler Fauls-Rivas and was guided on a virtual tour of the facility. Current census observed was 9 school age children and 2 staff. A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.
LPA reviewed copies of the amended report to director.

Exit interview was conducted. The report was read and reviewed with the director. A copy of the report and their appeal rights (LIC 9058) was emailed to Director with a Read Receipt requested to acknowledge report was received. Director was asked to respond to email by copying and pasting “I have read and received the Report, I acknowledge receipt.” Report LIC 809 will also be mailed if those options are not available.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Sherene Hawkins
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2021
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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