Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413059
Report Date: 01/06/2017
Date Signed 01/06/2017 03:44:41 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 @ JACKSON OAKS ELEMENTARYFACILITY NUMBER:
434413059
ADMINISTRATOR:MARIA BETANCOURTFACILITY TYPE:
840
ADDRESS:2700 FOUNTAIN OAKS DR ROOM10TELEPHONE:
(408) 972-5132
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:30CENSUS: 0DATE:
01/06/2017
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Maia Skreen & Maria "Myra" BetancourtTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Zakiya Ali, conducted an announced case management visit to the Facility today in response to an increase of capacity request. LPA met with Maia Skreen, program director, and Maria "Myra" Betancourt, director, and explained the nature of today's visit to them. The Facility is currently licensed on the campus of Jackson Elementary School in Room 10 and is adding the cafeteria and library to the license to increase the license to a total of 50 school age children.

LPA notes that the Facility is operating at a functioning elementary school site, and thus the facility is exempt from the indoor and outdoor square footage requirements, fencing requirements, toilet/sink ratios, and isolation area requirements. No measurements were taken of the indoor and outdoor spaces during today's visit. LPA has received a capacity letter, signed by the principal of Jackson Elementary School, indicating that each room can accommodate a maximum of 30 children each.

LPA toured the facility both inside and out during today's visit. There is a bathroom, located in Room 10, and separate 'Girls' and 'Boys' bathrooms located by the playground area for the children's use. The bathrooms provide individual privacy. Only cold water is available in the children's sinks. Staff have a separate bathroom from the children which is located in the hallway leading to the playground area. LPA observed no fireplaces or wall heaters at the facility.

The center only provides snacks for the children and the food preparation area is located in Room 10. The kitchen area includes a sink with hot/cold running water, dishwasher, microwave, toaster oven, and refrigerator. Disposable dishes and utensils are provided. Sanitation will be completed by hand washing. Trash cans with tight-fitting lids are located throughout the facility for the disposal of solid waste.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 01/06/2017):
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2


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 @ JACKSON OAKS ELEMENTARY
FACILITY NUMBER: 434413059
VISIT DATE: 01/06/2017
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 01/06/2017):

There are sufficient tables/chairs and hooks for at least 50 children at the Facility. The Facility utilizes the playground located by the restrooms on the back portion of campus. Additional staff will be available to escort the children to and from the playground. There is a climbing structure in the playground and there are sufficient wood chips under the play structure. Shade is provided by several large trees and building overhang.

A review of staff records on January 6, 2017 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

LPA received a fire clearance approval from the Morgan Hill Fire Department prior to today's visit.

No deficiencies issued during today's visit.

LPA conducted an exit interview with Maia and Myra prior to the conclusion of today's visit and advised them that a license for 50 school age children is approved effective today, January 6, 2017.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2017
LIC809 (FAS) - (06/04)
Page: 2 of 2