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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 566212190
Report Date: 09/17/2025
Date Signed: 09/19/2025 08:05:28 AM

Document Has Been Signed on 09/19/2025 08:05 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:CAMARILLO BRANCH - CAMARILLO FAMILY YMCAFACILITY NUMBER:
566212190
ADMINISTRATOR/
DIRECTOR:		JENNIFER HEINEN-STIFFLERFACILITY TYPE:
840
ADDRESS:3111 VILLAGE AT THE PARK DR.TELEPHONE:
(805) 484-0423
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY: 44TOTAL ENROLLED CHILDREN: 44CENSUS: 9DATE:
09/17/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:58 PM
MET WITH:Cameron PizzaroTIME VISIT/
INSPECTION COMPLETED:
04:19 PM
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On 09/17/25 at 1:57 PM, Licensing Program Analysts (LPAs) Cynthia Alvarez & Veronica Diaz conducted an unannounced Annual inspection. LPAs met with front staff member Andrew Aleman and indicated that Site Supervisor was out picking up children from schools, at 2:23PM site supervisor Cameron Pizzaro arrived and advised them of the purpose of the inspection. Site Supervisor provided LPAs a tour of the center inside and out. There were 15 children in care at the time of the inspection under the care of 3 staff. This site is an after-school program. Center is open M-F, from 7:00AM- 8:30AM and then again 12:30PM - 6:00PM.

LPAs observed required licensing documents posted on the wall at the entrance of the classroom. The center utilizes the 1 classroom room and the gymnasium , and outdoor yard for children in care. LPAs observed 2 restrooms available for children in care, 1 restroom is outside the classroom in the public area of the facility ; however, Site Supervisor advised LPAs that staff members walk children to the restroom and wait for them. LPAs did not observe any hazards/toxins items accessible to children in care. The First Aid kit was observed in the cabinet of the classroom. The classroom contained age-appropriate furniture readily accessible for children. The outdoor playground has ample amount of space for children to play. The playground has appropriate toys and structures available for children to use. There is drinking water available indoors and outside for the children in care. The facility has a swimming pool on the premises; however, the center has multiple doors with a coded lock on each preventing children from having access to the pool. Currently, the center uses an App called ePact for sign-in and sign-out. Site supervisor stated the school provides biweekly and monthly newsletters with snack menu. Site supervisor informed LPAs that the center provides an afternoon snack.

(Continued on LIC808-C)

NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Cynthia Alvarez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2025
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
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: CAMARILLO BRANCH - CAMARILLO FAMILY YMCA
FACILITY NUMBER: 566212190
VISIT DATE: 09/17/2025
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A sample of 4 children and 4 staff records were reviewed. LPAs observed children's files to be complete and current, they contained emergency identification and notification of parent’s rights. A review of staff records was conducted. All 4 Staff mandated reporter certification were reviewed and found to be current. LPAs reviewed SB792 Child Care Adult Immunization and Tuberculosis requirements; however, 1 staff member did not that record of their immunization on site, they stated they submitted to administration staff. The center will email immunization record to LPA once they obtain a copy. Last fire drill was conducted on 08/28/25.

Site supervisor 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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/ .

Site supervisor was informed of the MyChildCarePlan.org website; 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.

No citations were given; however, 1 technical violation was given during today's inspection.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the site supervisor Cameron Pizzaro.

NAME OF LICENSING PROGRAM MANAGER: Susana Martinez
NAME OF LICENSING PROGRAM ANALYST: Cynthia Alvarez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC809 (FAS) - (06/04)
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