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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364816543
Report Date: 03/07/2024
Date Signed: 03/07/2024 05:01:48 PM

Document Has Been Signed on 03/07/2024 05:01 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:YMCA-HIGHLAND GROVE SCHOOL AGE SITEFACILITY NUMBER:
364816543
ADMINISTRATOR:FIELD, CRISTYFACILITY TYPE:
840
ADDRESS:7700 ORANGE ST.TELEPHONE:
(909) 735-6836
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 89TOTAL ENROLLED CHILDREN: 89CENSUS: 23DATE:
03/07/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
02:39 PM
MET WITH:Natalie RiveraTIME COMPLETED:
05:10 PM
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On 03/07/2024 at time listed above Licensing Program Analyst (LPA) Justin Giese arrived at the facility to conduct a 1 year required annual inspection. LPA was granted entry by Site Director, Natalie Rivera. LPA toured the facility, inside and out, reviewed records, and observed and/or discussed the following:

Normal days and hours of operation are: Monday - Friday, 1:50pm to 6:00pm

A review of the staff records and review of a sampling of children's records were conducted as part of this evaluation.

The inspection consisted of reviews of the following domains:
• Food Service
• Reporting Requirements
• Physical Plant
• Care and Supervision
• Children Records
• Staff Records
• Staffing Ratio and Capacity
• Personal Rights

The inspection found the facility to be in compliance in these domains, except where noted on LIC809D
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: YMCA-HIGHLAND GROVE SCHOOL AGE SITE
FACILITY NUMBER: 364816543
VISIT DATE: 03/07/2024
NARRATIVE
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The licensee is asked to update the following documents, if applicable, and submit to licensing within 30 days:
1. LIC 500 Personnel Report
2. LIC 610 Emergency & Disaster Plan
3.Parent Handbook/ Program Curriculum/Admission policies and procedures/ fee schedule (only if changes have been made)
4. LIC 309 Administrative Organization
5. LIC 308 Designation of Administrative Responsibility

• The following items have been posted and are updated where necessary:
License, Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148)
Parent’s Rights Poster (PUB393), Personal Rights (LIC613A); Child Car Seat Law, Menu
• The facility is operating within the terms of the license
• Appropriate supervision was provided during this inspection
• Classrooms are equipped with age appropriate furniture and equipment in good condition
• Classrooms are clean and free of hazards
• No weapons stored at the facility
• There are no accessible bodies of water present. All wading pools or similar product must be emptied immediately after use and stored in an upright position.
• Medications are stored where inaccessible to children
• Hazards are stored where inaccessible to children which include: Disinfectants, cleaning solutions and other items that are dangerous
• Poisons and toxins are locked: Located in on-site janitorial closet
• All floors are clean and safe
• Bathrooms were observed to be safe, sanitary and in operating condition
• Playgrounds are enclosed by appropriate fences and free of hazards
• Outdoor activity areas are supplied with age and size appropriate equipment in good condition
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: YMCA-HIGHLAND GROVE SCHOOL AGE SITE
FACILITY NUMBER: 364816543
VISIT DATE: 03/07/2024
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• All storage containers for solid waste, including moveable bins-have tight-fitting covers and in good repair
• Uncontaminated drinking water readily available both indoors and out
• The areas around or under high climbing equipment, swings, slides, and similar equipment shall be cushioned with material that absorbs a fall: grass/wood chips
• Sign in/Sign out record was reviewed and meets regulation requirements
• A Staff member is present with current Pediatric CPR/First Aid which expires on 07/2025
• Opening and closing staff member’s CPR/First Aid expires on 07/2025
• Director completed Health and Safety Training and on file
• Staff files were reviewed – Please see LIC809D for Type B deficiencies for missing documentation.
• Staff have received on the job training for house keeping, sanitation and universal health precautions
• Records reviewed for children in care all contained proper Identification and Emergency contact Information

Licensee was informed of the Department has inspection authority per Health and Safety Codes sections: 1596.852, 1596.853 and 1596.8535.

• Documentation of fire & earthquake drills to be conducted every six months: Last drill on 01/26/2024

Licensee was informed of Unusual Incident Reporting email:

UnusualIncidentReportsDO09@DSS.CA.Gov
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: YMCA-HIGHLAND GROVE SCHOOL AGE SITE
FACILITY NUMBER: 364816543
VISIT DATE: 03/07/2024
NARRATIVE
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Reminders:

Facility representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During this inspection LPA was unable to verify Criminal Records Clearance for Staff 2. See LIC809D for Type A deficiency.

A Civil Penalty of $500 will be assessed during this inspection for Staff Criminal Record Clearance.

Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”.

YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: YMCA-HIGHLAND GROVE SCHOOL AGE SITE
FACILITY NUMBER: 364816543
VISIT DATE: 03/07/2024
NARRATIVE
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and
administrative records.

For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience.
If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process

LPA issued a Notice of Site Visit and verified it was posted in a prominent location at the facility. Licensees understands that the Notice of Site Visit must remain posted for the next 30 days along with a copy of all Type A deficiencies cited during this inspection. A copy of all Type A deficiencies cited during this inspection must also be immediately (within 24 hours of child’s next day in care) given to the parents of all children enrolled in the child care facility and any children enrolled into the child care facility over the next 12 months (at the time of enrollment). Licensees are required to have all parents sign and date the Acknowledgement of Receipt of Licensing Reports (LIC9224) and maintain a copy in each child’s file. A copy of this report, LIC9224 and Appeal Rights (LIC9058) were provided during this inspection.

Exit interview conducted and report was reviewed with the Site Director, Natalie Rivera.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Justin Giese
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 03/07/2024 05:01 PM - It Cannot Be Edited


Created By: Justin Giese On 03/07/2024 at 03:54 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: YMCA-HIGHLAND GROVE SCHOOL AGE SITE
FACILITY NUMBER: 364816543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, interview, and staff records/facility roster review the licensee did not comply with the section cited above. LPA was unable to verify proper criminal records clearance for Staff 3, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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Facility Director was made aware that criminal records clearance was unavailable for Staff 3. As a result, Staff 3 left the premisis. They will be unable to return to the facility until criminal records clearance is established. Facility will provide written statement regarding importance of this regulation and submitt to LPA on of before stated POC date of 03/08/2024.
Submission can be made via email: justin.giese@dss.ca.gov ** $500 civil enalty will be assessed
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Gilbert Sena
LICENSING EVALUATOR NAME:Justin Giese
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 03/07/2024 05:01 PM - It Cannot Be Edited


Created By: Justin Giese On 03/07/2024 at 03:54 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: YMCA-HIGHLAND GROVE SCHOOL AGE SITE
FACILITY NUMBER: 364816543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and staff records reviewed, the licensee did not comply with the section cited above. LPA was unable to verify immunization recrords (MMR/Tdap) for Staff 2, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2024
Plan of Correction
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Facility Director was made aware Staff 2's immunization records was not available. Facility will obtain Staff 2's immunization records (MMR/Tdap) and provide proof to LPA on or before the stated POC date of 04/08/2024.

Submissions can be made by email: justin.giese@dss.ca.gov
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and staff records reviewed, the licensee did not comply with the section cited above. LPA was unable to verify TB screening within 1 year of employment for Staff 2, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2024
Plan of Correction
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Facility Director was made aware Staff 2's TB screening was not available. Facility will obtain Staff 2's TB screening and provide proof to LPA on or before the stated POC date of 04/08/2024.

Submissions can be made by email: justin.giese@dss.ca.gov
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:Gilbert Sena
LICENSING EVALUATOR NAME:Justin Giese
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 03/07/2024 05:01 PM - It Cannot Be Edited


Created By: Justin Giese On 03/07/2024 at 03:54 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: YMCA-HIGHLAND GROVE SCHOOL AGE SITE
FACILITY NUMBER: 364816543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and staff records reviewed, the licensee did not comply with the section cited above. LPA was unable to verify Health Screening Report for Staff 2, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2024
Plan of Correction
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2
3
4
Facility Director was made aware Staff 2's Health Screening was not available. Facility will obtain Staff 2's Health Screening and provide proof to LPA on or before the stated POC date of 04/08/2024.

Submissions can be made by email: justin.giese@dss.ca.gov
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Gilbert Sena
LICENSING EVALUATOR NAME:Justin Giese
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
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