Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 214005036
Report Date: 09/08/2016
Date Signed 09/08/2016 11:21:13 AM

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: 0DATE:
09/08/2016
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jayne Johnson and Kirsten MogensenTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Kistler met with Jayne Johnson and Kirsten Mogensen for an unannounced case management inspection. The facility requested to increase capacity of the program from 70 to 100. This facility currently operates at the Pleasant Valley Elementary School; a functioning school site. The facility operates in portables 1 and 2 (YMCA exclusive use) with use of the multipurpose room. The facility is requesting to add use of room D1, D3 and common space between the two rooms.

The facility is exempt from indoor square footage, number of toilets and their exclusive use, fencing, playground space and exclusive use of this space, and isolation toilets and isolation space. The outdoor space available to the children includes the three play structures, black tops and grassy areas throughout the campus. LPA toured the proposed new spaces, both are functioning classrooms during the school day and are ready for child care. Existing areas on the licenses, indoor and outdoor, were observed to be clean, safe and free from hazards. Fire clearance has been granted effective 8/16/16 for 100 children. Capacity increase will be approved effective today.

No deficiencies were observed today. Notice of site visit was observed to be posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Katie L KistlerTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2016
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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