Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434400382
Report Date: 03/30/2016
Date Signed 03/30/2016 11:24:32 AM


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/22/2016 and conducted by Evaluator Janet Tse
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20160322175429
FACILITY NAME:YWCA DAVIDSONFACILITY NUMBER:
434400382
ADMINISTRATOR:GABRIEL, LUCILLEFACILITY TYPE:
830
ADDRESS:350 SOUTH THIRD STREETTELEPHONE:
(408) 295-4011
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:10CENSUS: 8DATE:
03/30/2016
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Lucille GabrielTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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A bouncer was used in the infant room.
INVESTIGATION FINDINGS:
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At LPA Janet Tse's arrival, director Lucille Gabriel was not at the facility; and director arrived at the facility later. LPA observed eight infants with two teachers and one teacher assistant in the infant room.
LPA observed a bouncer/exersaucer in the crib area; and from the interviews conducted during the visit, it is confirmed that the bouncer/exersaucer has been used by the infants. LPA interviewed three staffs during today's visit. A copy of the roster of the children was provided to LPA.
Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12 & Chapter 1), are being cited on the attached LIC. 9099D.
LPA discussed the requirements of AB633 to director and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and director understands the requirements. Upon receipt, director shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Notice of site visit was issued and must be posted with type A deficiency cited for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2016
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 07-CC-20160322175429

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: YWCA DAVIDSON
FACILITY NUMBER: 434400382
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/30/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2016
Section Cited
101439(d)(2)
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H&S 1596.846(b)&(c) Infant Centers Fixtures, Fixture, Equipment, & Supplies.

LPA observed a bouncer/exersaucer in the crib area.
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The Infant Center must cease the usage of the bouncer/exersaucer and remove the item from the center.
Type A
03/31/2016
Section Cited
101223(a)(2)
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Personal Rights. Each child shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

LPA observed a bouncer/exersaucer in the crib area; and from the interviews conducted during the visit, it is confirmed that the bouncer/exersaucer has been used by the infants.
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The infant Center must cease the usage of the bouncer/exersaucer and remove the item from the center. Director shall submit a written plan of correction to ensure that each child shall be accorded safe, healthful and comforable accommodations, furnishings and equipments per Title regulations by 03/31/2016 due date.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.
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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2016
LIC9099 (FAS) - (06/04)
Page: 2 of 3