Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413059
Report Date: 02/03/2017
Date Signed 02/06/2017 04:28:10 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:50CENSUS: 24DATE:
02/03/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Maria Betancourt, DirectorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tony Studebaker conducted an unannounced, Annual/Random, inspection. LPA met with Maria Betancourt, Site Director, and explained the nature of today's inspection. The facility is located on the campus of Jackson Oaks Elementary. There were 24 school-age children with 3 teachers when the LPA arrived. The children were observed playing on the playground and library with two teachers providing supervision. LPA observed the required posted materials. The program operates Monday, Tuesday, Thursday, and Friday from 2pm-6:15pm and Wednesday 12:55pm-6:15pm. The facility is licensed for the library, room 10, and the cafeteria. LPA toured the facility both inside and outside during today's inspection. LPA observed that all classrooms and restrooms were clean, sanitary, and in good repair.

A review of staff records 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 the Director 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 violations within a 12 month period.

LPA reviewed a random sampling of the children's and staff files during today's inspection. All children and staff files reviewed were complete with the required forms. LPA reviewed the sign in and out sheets and found them to be in compliance. LPA also observed the care and supervision procedures of the facility during today's inspection and concludes that proper care and supervision requirements are being met. At minimum, one staff on site is trained in CPR and Pediatric First Aid. Certification expires March 2018. Facility conducts evacuation drills and the last drill was completed on 01/13/2017.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Anthony StudebakerTELEPHONE: (408) 334-8553
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2017
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 @ JACKSON OAKS ELEMENTARY
FACILITY NUMBER: 434413059
VISIT DATE: 02/03/2017
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LPA observed no bodies of water during today's inspection. Director states that there are no weapons on-site. No transportation is provided by the facility. There are adequate supplies, play equipment, and toys for children both indoors and outdoors. Drinking water is provided both indoors and outdoors. General care and supervision of the children, emergency evacuation procedures, and ratio/capacity were reviewed with the Director.

Licensing forms, title 22 regulations, and information can be obtained through the internet at www.cdss.ca.gov

No deficiencies were issued during the inspection. Exit interview conducted with the Site Director.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Anthony StudebakerTELEPHONE: (408) 334-8553
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2017
LIC809 (FAS) - (06/04)
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