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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013418512
Report Date: 03/09/2022
Date Signed: 03/09/2022 03:33:28 PM


Document Has Been Signed on 03/09/2022 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:YAROSHEVSKAYA, ANNAFACILITY NUMBER:
013418512
ADMINISTRATOR:YAROSHEVSKAYA, ANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 828-3071
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:12CENSUS: 6DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
03:45 PM
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On 3/9/2022 at 1:30pm Licensing Program Analysts (LPAs) Jaylena Miller and April Wright, met with licensee Anna Yaroshevskaya for an UNANNOUNCED ANNUAL REQUIRED INSPECTION. Present for the inspection were fingerprint cleared and associated assistant and 6 daycare children, and the licensee is within ratio today. Upon arrival LPA provided licensee a copy of form LIC 126. The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday-Friday 7:00am-6:00pm

The home is a two-story home with 4 bedrooms and 2 bathrooms on the second floor; The first floor consist of the family room, which is used as the main daycare area, half bathroom, living room, kitchen, dining room, garage and back yard. LPAs observed the home to be neat and clean with central heating and ventilation for safety and comfort.

The OFF-LIMIT AREAS are the entire second floor, kitchen, dining room, living room and garage, and will be inaccessible to children by locked doors, safety gates and visual supervision.

The ON-LIMIT AREAS are the family room and half bathroom. The designated isolation area will be the area in front of the window. The backyard will be a designated outdoor play area that is fully fenced. The outdoor area has age appropriate toys and furnishings that LPAs observed to be clean and free from defects and dangerous conditions.

All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged fire extinguisher 1A-10-BC, working smoke/carbon monoxide detector combo, telephone and fully stocked first aid kit. There are no pools, hot tubes or any other bodies of water present at the time of the inspection. Per licensee, there are no firearms on the premises.

The licensee has not completed the Health and Safety training and LPAs will provide information on the class, licensee and assistant is registered/paid for CPR/First Aid and the training is scheduled for 3/25/2022. The licensee and assistant have not completed the mandated reporter training. The licensee conducts and documents fire and disaster drills twice a year and the last conducted drill was on 1/4/2022. All required forms are posted and visible for public review.

Please see LIC 809-C for continuance

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: YAROSHEVSKAYA, ANNA
FACILITY NUMBER: 013418512
VISIT DATE: 03/09/2022
NARRATIVE
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At 2:00pm LPA Miller reviewed 6 children’s files and documented on LIC 857. There is a current roster available for review and copy obtained.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing 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

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPAs discussed the safe sleep regulations with licensee [or facility representative] and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPAs also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee was reminded of the responsibility as a mandated reporter and the trainings must be done once every two years as well as CPR/First Aid needs to be renewed every two years and must be EMSA approved. LPA also encouraged licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, as well as all forms can be downloaded. For licensing updates and Quarterly Child Care Distribution email, email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list.

Please see LIC 809-C for continuance
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: YAROSHEVSKAYA, ANNA
FACILITY NUMBER: 013418512
VISIT DATE: 03/09/2022
NARRATIVE
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Effective August 1, 2003 California Law requires Child Care licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624 within 7 business days.

After a complete inspection of the facility, the attached Type B deficiencies were cited, See LIC 809-D for deficiencies. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Anna Yaroshevskaya.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/09/2022 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: YAROSHEVSKAYA, ANNA
FACILITY NUMBER: 013418512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as the facility does not have a fire extinguisher 2A-10-BC or higher which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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Purchase a fire extinguisher that is 2A-10-BC or higher
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and records reviewed, the licensee did not comply with the section cited above in that the licensee and assistant S2 do not have current Mandated Reporter Training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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Licensee and Assistant S2 must take and complete the required Mandated Reporter training at mandatedreporterca.com

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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 03/09/2022 03:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: YAROSHEVSKAYA, ANNA
FACILITY NUMBER: 013418512

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and records reviewed, the licensee did not comply with the section cited above in that the licensee and assistant S2 do not have proof of immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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Licensee will create complete files for both the licensee and assistant S2
Type B
Section Cited
CCR
102416.1(a)(6)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information: (6) Documentation of completion of training on preventative health practices as required by Section 102416(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and records reviewed, the licensee did not comply with the section cited above in she does not have a certificate of completion of Preventative health practices which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2022
Plan of Correction
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Licensee will register/pay for Preventative Health and Safety training or provide copy of certification of completion of Preventative Health and Safety training at Admas Safety or contact Hively.

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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
LIC809 (FAS) - (06/04)
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