Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005036
Report Date: 09/18/2015 12:00:00 AM
Date Signed 09/18/2015 03:39:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MARIN YMCA @ PLEASANT VALLEYFACILITY NUMBER:
214005036
ADMINISTRATOR:KIRSTEN MOGENSENFACILITY TYPE:
840
ADDRESS:755 SUTRO AVENUETELEPHONE:
(415) 892-7476
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:70CENSUS: 44DATE:
09/18/2015
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Director of Youth Development, Jayne JohnsonTIME COMPLETED:
04:00 PM
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Licensing Program Analyst, Cindy Interiano made an unannounced Case Management visit today and met with Director of Youth Development, Jayne Johnson. Purpose of the visit was explained to Director. Program is requesting a change of classroom from C-4 to B-4 at the Pleasant Valley Elementary School Site. A Superintendent of Schools Certification from the Novato Unified School District for use of Room B4 is on file.
LPA toured and inspected Classroom B4. Program will have exclusive use of the classroom afterschool as a 'homework station.' Program will also have exclusive use of boys and girls restroom adjacent to classroom.

An updated License will be issued to include use of Room B4.

>No deficiencies were cited today under CCR, Title 22, Division 12, Chapter 3.

>This report and rights to comment and appeal were discussed with Director. This report must be available in the facility for public review. Notice of site visit was posted.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8843
LICENSING EVALUATOR NAME: Cindy InterianoTELEPHONE: (650) 266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2015
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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