Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434400382
Report Date: 01/20/2017
Date Signed 01/20/2017 06:15:49 PM


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
01/12/2017 and conducted by Evaluator Janet Tse
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20170112102545
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: 3DATE:
01/20/2017
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Lucille GabrielTIME COMPLETED:
06:20 PM
ALLEGATION(S):
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Children have access to hazardous items.
INVESTIGATION FINDINGS:
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LPA Janet Tse met with director Lucille to open investigation for the above allegation. LPA toured the facility indoor and outdoor. LPA observed three children with two teachers and one teacher assistant in the Infant Room.
LPA observed a bottle of bleach solution placed on a 4 ft high divider in between the Toddler and Infant bathroom, accessible to children.
Based on LPAs observations which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulation, (Title 22, Division 12 & Chapter 1), is 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.
Deficiency was cited. Notice of site visit was issued and must be posted wih 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: 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.
LIC9099 (FAS) - (06/04)
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Control Number 07-CC-20170112102545

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: 01/20/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2017
Section Cited
101238(g)
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Buildings and Grounds. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children shall be inaccessible to children.

LPA observed a bottle of bleach solution placed on a 4 ft high divider in between the Toddler and Infant bathroom, accessible to children.
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Director instructed the staff to remore the bleach solution to a high shelf inaccessible to children during the visit. Deficiency was cleared today. Director shall conduct a meeting with staff to ensure that all items that are dangerous to children shall be inaccessible to children. Director shall forward a copy of the minutes with the attendees signatures by 02/03/2017.
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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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3