Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613958
Report Date: 03/08/2016
Date Signed 03/08/2016 04:38:54 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: 42DATE:
03/08/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Elizabeth Medina - Site DirectorTIME COMPLETED:
05:00 PM
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LPA Jane Cong-Huyen met with the site director, Elizabeth Medina, for a random annual visit (2). LPA toured the facility, including all activity/classroom areas, the isolation area, rest-rooms and outdoor play areas. This facility is located in the portable building # M-3 located on Loma Vista Elementary School site. LPA observed 42 school-age children with 4 staff including the site supervisor. A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reviewed care and supervision of children, staffing ratios, health related services, including medications and first aid supplies, furniture, equipment, fire drills, drinking water and food service provisions. LPA observed all required forms to be posted. Medications are stored in a cabinet inaccessible to children in care. Some first aid materials were available. There are adequate toys and equipment available for children. The rest-room was observed to be in working order. The facility also use the school restrooms during after school hours when the regular elementary school children are no longer on campus. The facility provides breakfast and afternoon snack. The program operates from 7:00a.m.- 6:00p.m. LPA reviewed the sign/in-sign/out sheet, children's and personnel records. At least one staff member present today have current Pediatric CPR and First Aid throughout the day. The facility has working carbon monoxide detector and smoke detector. LPA reviewed staff and children's files as well as LIC500 and children's roster. LPA discussed about Incidental Medical Services (IMS) with the director. YMCA has submitted a written IMS plan/procedure to CCLD but still need individual physician note(s) from each child that is currently on IMS and required licensing form in file. Director will be submitting the requested document for the few children that is currently on IMS and the staff responsibility page by before or by 3/31/16.
No deficiency cited during today's visit.
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. LPA informed the director of how to access regulations and forms from CCLD websites: www.ccld.ca.gov or Myccl.ca.gov and http://ccld.ca.gov/PG411.htm. This report is to be on file and accessible for public review at the facility for at least 3 years.
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2016
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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