Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434400383
Report Date: 03/14/2017
Date Signed 03/14/2017 03:48:18 PM

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:YMCA POMEROY MILPITASFACILITY NUMBER:
434400383
ADMINISTRATOR:WATERS, CYNTHIAFACILITY TYPE:
840
ADDRESS:1505 ESCUELA PARKWAYTELEPHONE:
(408) 298-3888
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:50CENSUS: 23DATE:
03/14/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Frances MoodieTIME COMPLETED:
04:00 PM
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Licensing Program Analyst Esther Adeyemi met with Site Director Frances Moodie to conduct an unannounced Annual/Random visit. During today’s visit, analyst's toured the facility building and grounds, reviewed a sampling of children and teacher files report and TB results .

A review of staff records indicates that all staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
During today’s visit, analyst's observed the following: Ratios were in compliance; CPR/First Aid for at least one staff person were on file; sign in and out sheets were reviewed and found in compliance; fire extinguisher maintenance is current for extinguisher maintenance; required forms were posted and up to date; drinking water is available indoors and outdoors; there is adequate storage for children’s belongings; children’s bathroom were clean however cleaning solution was in an unlocked cabinet inaccessible to children. Paper products are available; menus are posted and in compliance. . First aid supplies are available and properly maintained; furniture and equipment is age appropriate and in good repair. Outdoor equipment is age appropriate, in good repair and resilient material is adequate. The facility is found to be clean, safe and sanitary today.


REPORT CONTINUED ON THE FOLLOWING PAGE
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Esther AdeyemiTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2017
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: YMCA POMEROY MILPITAS
FACILITY NUMBER: 434400383
VISIT DATE: 03/14/2017
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CONTINUATION OF PREVIOUS PAGE

Any medication would be kept in the office shelf inaccessible to children.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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 deficiency was cited today.

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

SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Esther AdeyemiTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2017
LIC809 (FAS) - (06/04)
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