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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561709990
Report Date: 10/22/2024
Date Signed: 10/22/2024 03:56:55 PM

Document Has Been Signed on 10/22/2024 03:56 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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:SIMI VALLEY FAMILY YMCA - HOLLOW HILLSFACILITY NUMBER:
561709990
ADMINISTRATOR/
DIRECTOR:		JAMIE GONZALEZFACILITY TYPE:
840
ADDRESS:828 GIBSONTELEPHONE:
(805) 527-5730
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 47DATE:
10/22/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Kareena HadapTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 10/22/24, at 1:50 PM, Licensing Program Analyst (LPA) Elvin Baddley conducted an unannounced Three Year Required inspection of the abovementioned Child Care Center (CCC). LPA met with Kareena Hadad, Director of the CCC. LPA explained the purpose and nature of the inspection to Director. The facility is located on the grounds of Hollow Hills Elementary School. The school-age program operates Monday – Friday 1:45 PM- 6:00 PM. The CCC's hours of operation are modified from 1:00 PM- 6:00 PM when the elementary school releases students at 1:05 PM. The CCC uses a module classroom which is subdivided in to two room (Play Room and Homework Room). At the time of inspection, LPAs observed 47 children on site, along with four teachers. The CCC's Director is assisting with the care and supervision of children on site.

LPAs observed required licensing forms and documents posted near entry door of the CCC. The CCC has a schedule of activities posted on the room wall. The CCC has an electronic Sign In/Out system (Daxko). LPA reviewed system entries and observed the arrival and departure times of children in care and well as the electronic signatures of the children's authorized representatives. Disinfectants, cleaning solutions and sharps are located in a locked cabinet underneath the sink. The CCC has no medications on site. Director informed LPA medications are stored in a locked cabinet when on site. The classroom of the CCC is clean and orderly. The classroom has age appropriate equipment and furnishings available to children in care. The CCC's carbon monoxide detector was tested at 2:40 PM and found to be operable.



The CCC uses two restrooms. All restrooms are in sanitary operating condition. The CCC shares the restrooms with other children in school, however CCC children are monitored by CCC staff when using the restrooms. LPA observed a refrigerator in the classroom which contained food for the children. The CCC provides an afternoon snacks to children in care. Lunch is not provided to children in care at the CCC. The CCC has supplemental food in the event additional food is needed. The CCC also has available bottled drinking water for children inside and outside of the facility. CCCs constructed before 1/1/20, to test their water (used for drinking and food preparation) for lead contamination (CONT. LIC 809-C, Page 2)
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: SIMI VALLEY FAMILY YMCA - HOLLOW HILLS
FACILITY NUMBER: 561709990
VISIT DATE: 10/22/2024
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before 1/1/23, and then every 5-years after the date of the first test. For child care center licenses issued after 7/1/22, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

The CCC outdoor playground areas are enclosed within the elementary school's wrought iron fencing. The fence’s entry/exit gates are secured. The surfaces of the outdoor playground areas are varied. LPA observed age appropriate play equipment in the play areas. Children in care do not use the school's play structures. LPA observed no bodies of water on site.

A sampling of staff and children records were reviewed. The children’s records were complete and found to contain emergency contact information, among other required licensing documentation and forms. Staff records were reviewed. Staff records sampled were complete and found to contain First Aid/CPR certifications (EMSA approved) and Mandated Reporter Training certification, among other required licensing documentation and forms. LPA notes the last disaster drill at the facility occurred on 10/17/24. Director informed LPA no firearms or ammunition are stored on site.

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/.

Facility representative was reminded that all adults 18 and over, including employees and volunteers,
as specified in HSC 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.

Facility representative was informed of the MyChildCarePlan.org website; (CONT. 809-C, Page 3)
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: SIMI VALLEY FAMILY YMCA - HOLLOW HILLS
FACILITY NUMBER: 561709990
VISIT DATE: 10/22/2024
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a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Facility representative Kareena Hadap.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Elvin Baddley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC809 (FAS) - (06/04)
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