Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613958
Report Date: 01/20/2017
Date Signed 01/20/2017 04:49:42 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:79CENSUS: 39DATE:
01/20/2017
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Elizabeth Medina - Site Supervisor TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Jane Cong-Huyen met with the Site Supervisor, Elizabeth Medina, for a case management - licensee initiated visit for an increase in capacity. The facility is currently licensed for 53 children in Portable YMCA. The facility has been approved by the elementary school to use the school's Multipurpose Room to increase the capacity to 92 children. A letter from the principal for this approval is on file.

LPA toured the facility inside and outside and observed 39 school-age children with 5 staff including the site supervisor. During today's visit, LPA inspected and measured the multipurpose room. LPA also reviewed some children's files with IMS.

Portable (YMCA) was previously measured for 1,863 divided by 35 = 53 children
Classroom B-4 was also previously measured for 893 ft. divided by 35 = 25 children
Elementary School Multipurpose Room (MPR) 33.5 x 55.3 = 1,853 divided by 35 = 52 children
The facility have access to the elementary school playground area and grass area which can accommodate over the requested amount of children. There are bathrooms with 8 toilets, 3 urinals and 8 sinks within the 4 bathrooms for the children to use which can accommodate up to 120 children.

At this time, the facility is requesting for 92 school-age children. The facility can accommodate up to 92 children. The YMCA portable building can accommodate up to 53 children, B-4 can accommodate up to 25 children and in MPR = 53 children. Classroom B-4 is only use for emergency situation and/or overflow only.

The facility has a water dispenser in the classroom for children to have access to water and drinking fountains outside on the play yard area.

The children will use the elementary school playground for outdoor play area which can accommodate more than 100 children.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2017
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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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: 01/20/2017
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(Case Management Visit, Page 2)

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

No violation cited during today's visit.

***The facility is approved for a license of 92 school-age children effective 1/23/2017. ***



Exit interview was conducted. Report reviewed and discussed. 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 provided and explained if violation was issues. The director/licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. LPA informed the director/licensee of how to access regulations and forms from CCLD websites: www.ccld.ca.gov or Myccl.ca.gov. This report is to be on file and accessible for public review at the facility for at least 3 years.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2017
LIC809 (FAS) - (06/04)
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