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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300614092
Report Date: 06/22/2021
Date Signed: 06/22/2021 02:37:04 PM

Document Has Been Signed on 06/22/2021 02:37 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:SADDLEBACK YMCA-ARROYO VISTA PROGRAM CENTERFACILITY NUMBER:
300614092
ADMINISTRATOR:GONZALEZ, SUZANNAFACILITY TYPE:
840
ADDRESS:23371 ARROYO VISTATELEPHONE:
(949) 589-8502
CITY:RANCHO STA MARGARITASTATE: CAZIP CODE:
92688
CAPACITY: 135TOTAL ENROLLED CHILDREN: 0CENSUS: 39DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:DirectorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA),Mahnaz (Nancy) Malek conducted an on site inspection for the purpose of an Annual Required- 1 year. The Covid-19 Emergency Response questionnaire was reviewed and answered by the director, Suzanna Gonzalez. LPA toured the facility inside and outside and the floor and yard plan (LIC 999) were verified. This facility runs a before and after school, and summer program. There were 39 school age children present with 4 adults staff including the director. Due to COVID 19 guidelines, LPA observed staff and children wearing face mask, social distancing and following CDC and Dept of Public Health Guidelines. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
During the inspection of the indoor activity space, items which could pose a danger to children (detergents, are provided by parents. Menu was posted where they could be reviewed by parents. Floors, equipment, and furniture were clean and were observed to be in good repair and free of sharp edges. There is drinking water available to children indoors and outdoors. The children's bathrooms are clean and sanitary. The facility has conducted an emergency drill within the past six months. The facility has a working carbon monoxide detector. Facility met all posting requirement. The California Child Passenger Safety Law was posted by the entrance of the facility.

Staff files were reviewed for staff present during the facility inspection on this date. Five staff files were reviewed. Health screening and immunization as required were reviewed. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2021
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SADDLEBACK YMCA-ARROYO VISTA PROGRAM CENTER
FACILITY NUMBER: 300614092
VISIT DATE: 06/22/2021
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against pertussis, measles for staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. All the staff met this requirement. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications. Three staff had current certificates.
The director was informed that the Criminal Record Statement (LIC 508) has been updated, and the facility must now use the new form with revised date 7/15. She was also informed that the LIC 508 must be submitted with all Criminal Background Clearance. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian.
Children's records were reviewed, and there was a separate, complete and current record for each child. A random sample of (5) of children's files were reviewed for documentation of the child’s name, address, and telephone number of the child’s authorized representative and of relatives or others that can assume responsibility for the child if the authorized representative cannot be reached when necessary (LIC 700). In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day. (The facility has electronic sign in/out program).
The medication stored were reviewed. 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
The outdoor activity space was inspected for compliance. The playground was enclosed by a fence at
least four feet in height. The surface of the outdoor activity space was well maintained and free of hazards. The cushioning material produced for the purpose around the climbing equipment, swings, slides and other similar equipment appeared to be enough to absorbs falls. The outdoor equipment and toys were in good repair and free of sharp edges. There are no bodies of water present at the facility. The facility grounds were safe, sanitary and in good repair. (The facility uses the elementary school's outdoor playground and space)
The director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov The facility has been added to email list to receive Quarterly Update from the Department.
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SADDLEBACK YMCA-ARROYO VISTA PROGRAM CENTER
FACILITY NUMBER: 300614092
VISIT DATE: 06/22/2021
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Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The director was informed, and website given, about the California Child Care Disaster Plan which has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org

A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative. In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at this inspection date.

An exit interview was completed with director. The report was reviewed and discussed. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. The director was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. The “Notice of Site Visit” must be posted on or adjacent to the door. Failure to post will result in Civil Penalties of $100.00.

End of the report.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mahnaz Malek
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
LIC809 (FAS) - (06/04)
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