Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613958
Report Date: 08/31/2015 12:00:00 AM
Date Signed 08/31/2015 04:13:27 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:CENTRAL ORANGE COAST YMCA - LOMA VISTA SCHOOLFACILITY NUMBER:
300613958
ADMINISTRATOR:MEDINA, ELIZABETHFACILITY TYPE:
840
ADDRESS:13822 PROSPECT AVE.TELEPHONE:
(714) 730-0541
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:65CENSUS: 0DATE:
08/31/2015
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Elizabeth Medina - DirectorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jane Cong-Huyen met with the director, Elizabeth Medina, for a case management incident visit. The facility self-reported an incident that happened on 8/12/15 when the facility went on a field trip to Knott's Berry Farm. During the field trip, a child (child #1) left the group of children and was unsupervised by YMCA staff for approximately 10 minutes. Half of the children went on the ride with staff #3 and half of the staff stayed back with staff #2 at the location at the end of the ride. Staff #2 started to move the children to another area but did not count all of the children and left child#1 back when child#1 was purchasing a drink. The child went to an attendant at the park and was returned to another group of YMCA children and later was returned to the appropriate group. During today's visit, LPA interviewed staff and learned that the staff (staff #2) who was responsible for caring for child#1 during the field trip is no longer working for the YMCA at this time. The director admitted that it was staff #2's fault for not counting the children and paying attention to where all of the children were at.

LPA toured the school and during the visit, there were no children present. The children are off today because first day of school is tomorrow. During today's visit, LPA conduct interviews and reviewed records.

Violation with cited during today's visit. Deficiency page attached on continuation page.

An immediate $150.00 assessed during today's visit.

The same violation was cited on 8/21/13.
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2015
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CENTRAL ORANGE COAST YMCA - LOMA VISTA SCHOOL
FACILITY NUMBER: 300613958
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2015
Section Cited
101229(a)(1)
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Care and Supervision - No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). A child was left behind from the group during a field trip & was unsupervised for approximately 10 minutes.
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Director stated that she already spoke to each staff individually regarding to supervision issue & reminded them to use the "name-to-face" procedure at all times especially during transition time and during field trip. Director submitted the minutes of the staff meeting regarding to supervision issue with staff signatures.
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In accordance with the California Health and Safety Code Section 1596.99(c), you are hereby notified that an immediate $150 civil penalty per violation, followed by $150 per day per violation will be assessed until corrected.

Facility was cited for the same issue on 8/21/13.
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**Deficiency cleared during today's visit**
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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: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2015
LIC809 (FAS) - (06/04)
Page: 3 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: CENTRAL ORANGE COAST YMCA - LOMA VISTA SCHOOL
FACILITY NUMBER: 300613958
VISIT DATE: 08/31/2015
NARRATIVE
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Case Management Report, page 2

Exit interview was conducted. The Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Appeal Rights explained. All appeals must be in writing and received by the licensing office within 10 days. This report is to be on file and accessible for public review at the facility for at least 3 years.


If/when licensee/facility is cited any Type A citation/deficiencies, facility is to provide copies of the LIC809 and LIC809C/D pages with a receipt form LIC9224 within 24 hours or next day the child return to the facility. Facility Evaluation Report and LIC809D Facility Evaluation Deficiency Report with the Type A citation to parents/legal guardians of children in care and to parents/legal guardians of children newly enrolled at the facility during the subsequent 12 months after insurance. Licensee needs to keep verification of receipts in each child's file at the facility. Failure to post Type A report(s) for 30 days will result in civil penalty of $100.
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2015
LIC809 (FAS) - (06/04)
Page: 2 of 3