Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376600553
Report Date: 07/13/2016
Date Signed 07/13/2016 01:07:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:SO. BAY FAM. YMCA - THURGOOD MARSHALLFACILITY NUMBER:
376600553
ADMINISTRATOR:LUISA PENAFACILITY TYPE:
840
ADDRESS:2295 MACKENZIE CREEKTELEPHONE:
(619) 870-6422
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:60CENSUS: 0DATE:
07/13/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Karina Pina-ArmasTIME COMPLETED:
01:15 PM
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(3) Licensing Program Analyst (LPA) Iman Kayyali visited the facility to conduct an Annual Random site inspection. Upon arrival LPA met with Program Director Karina Pina-Armas, and proceeded to tour the facility. There were no children on site as facility is currently closed for summer break. School will be in session starting July 20, 2016. Facility operates a before and after school program Monday - Friday from 6-8:45am and from 3-6:30pm. Facility is licensed to operate in multipurpose room and room 704.

Furniture and age appropriate equipment is in good condition. Floors are clean and safe. Backpack storage are readily available and room accommodates class size. Bathrooms are safe and sanitary, maintained with operational toilets and faucets with appropriate temperature. Paper towels and toilet paper are available. Bathroom is lighted and has ventilation. Facility provides snacks. Children are provided drinking water from pitchers and outside from an operational water fountain. Food service area consists of a refrigerator which is clean and free of hazards. Trash cans have tight fitting covers in good repair. Cleaning supplies are kept locked and are inaccessible to children. Medication is stored in a locked cabinet inaccessible to children. There is at least one staff present with a current CPR and First Aid certification. Facility only uses block top area of playground which is fenced. Area has a canopies used for shade. This facility is currently providing Incidental Medical Services and has a plan of operation on file.

Isolation area is the inside room 704. Client records were reviewed for LIC 700 (Identification and Emergency Information) and Medical Assessment. No deficiencies were observed or cited during today's visit.

An exit interview was conducted. A copy of this report along with the Notice of Site Visit were left at the facility.
SUPERVISOR'S NAME: Debbie HanesTELEPHONE: (619) 767-2205
LICENSING EVALUATOR NAME: Iman KayyaliTELEPHONE: (619) 767-2223
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2016
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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