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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334841725
Report Date: 05/05/2025
Date Signed: 05/05/2025 02:36:12 PM

Document Has Been Signed on 05/05/2025 02:36 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:CORONA-NORCO FAMILY YMCA YOUTH CENTER AT JURUPAFACILITY NUMBER:
334841725
ADMINISTRATOR/
DIRECTOR:		MATTIE CRAMERFACILITY TYPE:
850
ADDRESS:9254 GALENA STREETTELEPHONE:
(951) 685-5241
CITY:JURUPA VALLEYSTATE: CAZIP CODE:
92509
CAPACITY: 164TOTAL ENROLLED CHILDREN: 164CENSUS: 75DATE:
05/05/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Anita JonesTIME VISIT/
INSPECTION COMPLETED:
10:22 AM
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On 05/05/2025 Licensing Program Analyst (LPA) Justin Giese made an unannounced visit to the facility to follow-up on the submission of an Unusual Incident Report (UIR). The UIR outlined an incident which occurred on 04/09/2025 pertaining to Personal Rights. LPA met with Facility Director, Anita Jones.

According to UIR on April 09, 2025 Facility Staff self-reported an incident where a child in care sustained a potential injury on the playground. UIR stated that around 10:45am, a child in care removed their shoes while playing outside on the facility playground. Staff witnessed the child remove their shoes and instructed the child to put their shoes back on due to potential safety concerns. It was stated the child retrieved their shoes and Staff was guiding the child by the hand to a location where they could assist the child in putting the shoes back on. UIR stated the child pulled away from staff while holding their hand and intentionally dropped/fell to the ground. It was stated after the child fell, they informed their wrist/arm had pain.

The parent/guardian of the child was contacted, and the child was picked up shortly after incident. UIR stated the parent/guardian contacted the facility the following day to inform that the child had been seen by a physician and it was determined they did not have any injuries. The child then returned to the facility without restrictions.

As part of this investigation, LPA interviewed all pertinent individuals and did not record any statement which lead to Staff intentionally pulling/tugging at the child prior to them intentionally falling to the ground. The incident appears to be accidental in nature and did not result in the child sustaining an injury.

NAME OF LICENSING PROGRAM MANAGER: Gilbert Sena
NAME OF LICENSING PROGRAM ANALYST: Justin Giese
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2025
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: CORONA-NORCO FAMILY YMCA YOUTH CENTER AT JURUPA
FACILITY NUMBER: 334841725
VISIT DATE: 05/05/2025
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LPA was provided with an incident/ouch report for the child's potential injury as well as a note from the child's physician stating they had been seen in care. The note did not disclose any injuries/treatments rendered.

Therefore, based on LPA observations, interview and records reviewed, there appear to be no violations of Title 22. Facility staff were present and quick to aid the child after the fall. Parent/guardian was notified immediately, and the Facility fulfilled its reporting requirements to Licensing.

An exit interview was conducted, LPA provided Director, Anita Jones with a copy of this report and a notice of site visit on 05/05/2025.

Notice of site visit must be displayed for the next 30 days.
NAME OF LICENSING PROGRAM MANAGER: Gilbert Sena
NAME OF LICENSING PROGRAM ANALYST: Justin Giese
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2025
LIC809 (FAS) - (06/04)
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