Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400382
Report Date: 05/30/2017
Date Signed 05/31/2017 07:51:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 DAVIDSONFACILITY NUMBER:
434400382
ADMINISTRATOR:RODRIGUEZ, JEANINEFACILITY TYPE:
830
ADDRESS:350 SOUTH THIRD STREETTELEPHONE:
(408) 295-4011
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:10CENSUS: 5DATE:
05/30/2017
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Lucille GabrielTIME COMPLETED:
04:25 PM
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An unannounced Required - 3 year visit was made by Roya Shahkarami. Analyst learned during today's visit that facility address is not correct and they are in process of working with previous analyst to fix it. Met with Lucille Gabriel since director, Jeanine Rodriguez was not available.

Analyst escorted to the infant room by director. Toured class room as well as playground. They have one active waiver for their playground. They share their playground with the preschool. Reviewed infants' needs and services. Needs & Services plans include individual feeding plans for each child and are updated at least once every three months or sooner if needed. They have a section of their class room designated for cribs. They have total of seven cribs. Sheets and toys are washed daily. Observed one napping child in the crib area which was under visual supervision. Analyst reviewed five children's and three staff's records. Each child's file reviewed contained Information and Emergency Information form (LIC 700) and Needs & Services Plans. Staff's records were all up to date. Analyst observed the infant room and crib area to be clean and safe. Drinking water is readily available for the children in each room and in the outdoor playground.
Lucille Gabriel stated that there are no firearm on the premises. Analyst didn't observe any bodies of water. Analyst observed all furniture and equipment are in good condition and safe for the children. The infant changing table has raised sides that are at least 3 inches in height. The infant changing table has a vinyl changing pad that is at least 1 inch think and in good condition. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Napping equipment is appropriate. The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. The infant playground is fenced and separate from the preschool playground. Analyst observed that the outdoor equipment is age appropriate and in good condition. There are sufficient resilient materials in the outdoor playground area. They have a main kitchen that prepares the center's meals. The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. Cleaning supplies are securely stored and inaccessible to the children. Sign in sign out sheet matched number of children in care.

See next page for continuation of the report:

SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2017
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: YWCA DAVIDSON
FACILITY NUMBER: 434400382
VISIT DATE: 05/30/2017
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Incidental Medical Services were discussed with the Lucille Gabriel. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.
Analyst discussed safe sleep for infants with director.
LPA advised the Director of the new immunization requirement (pertussis, measles, and flu vaccines) for all staff and volunteers that work directly with the children. Staff have all their updated immunization and CPR training.

No deficiency cited. Exit interview conducted, and a copy of this report was left at the facility.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2017
LIC809 (FAS) - (06/04)
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