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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421185
Report Date: 03/18/2022
Date Signed: 03/18/2022 04:23:41 PM


Document Has Been Signed on 03/18/2022 04:23 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, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:FIALKOWSKI, MARIA & STEVENFACILITY NUMBER:
013421185
ADMINISTRATOR:FIALKOWSKI, MARIA & STEVENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 778-0865
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:14CENSUS: 4DATE:
03/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Maria FialkowskiTIME COMPLETED:
04:38 PM
NARRATIVE
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On Friday, March 18, 2022, Licensing Program Analyst (LPA) Caroline Colson met with Maria Fialkowski for an unannounced random annual inspection at 2:02 PM. There are three (3) infants and one (1) preschool child present. Records were reviewed by the LPA and Licensee on March 18, 2022 at 2:45 PM. The home was toured to conduct a health and safety inspection.

The home is a two story home. The home consists of a living room, kitchen, downstairs bedroom which includes a bathroom, a second separate downstairs bathroom, two (2) closets, an upstairs bedroom with an office area, basement, garage and fenced back yard. The upstairs bedroom with an office area, downstairs bathroom located in the downstairs bedroom, two (2) closets, fenced back yard, basement and garage are the Off Limit Areas. The home has a 3A40BC fire extinguisher, working combination smoke and carbon monoxide detector. There are two properly screened working heaters. Licensee states there are no firearms in the home. The living room is the isolation room. Mrs. Fialkowski will be taking the children to the neighborhood park for outdoor play. She has a first aid kit. Mrs. Fialkowski has a small dog.




Please LIC 809 C for Additional information
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: FIALKOWSKI, MARIA & STEVEN
FACILITY NUMBER: 013421185
VISIT DATE: 03/18/2022
NARRATIVE
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· CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov


· Licensees and all staff are Mandated Reporters and are required to report to CCLD any suspected child abuse.

CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov

· Licensees may register to receive child care updates: www.myccl.ca.gov

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 ADA, available at: http://www.ada.gov/childquanda.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.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: FIALKOWSKI, MARIA & STEVEN
FACILITY NUMBER: 013421185
VISIT DATE: 03/18/2022
NARRATIVE
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Family Child Care Homes

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.

Safe Sleep

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] 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.

Notice of Site Visit

A notice of site visit was given and must remain posted for 30 days.

Exit Interview

Exit interview conducted and report was reviewed with the licensee, Maria Fialkowski

Please See LIC 809 D for Deficiencies. The attached type B deficiencies are being cited today and must be corrected by the due date.

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/18/2022 04:23 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, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: FIALKOWSKI, MARIA & STEVEN
FACILITY NUMBER: 013421185

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2022
Plan of Correction
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Licensee will register for another CPR and First Aid class.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review, the licensee did not comply with the section cited above in having a roster available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2022
Plan of Correction
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4

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: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 03/18/2022 04:23 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, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: FIALKOWSKI, MARIA & STEVEN
FACILITY NUMBER: 013421185

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in all four of the children's files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2022
Plan of Correction
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Licensee will complete the Infant Sleeping Plan for each child in care.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having any documentation for the infants in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2022
Plan of Correction
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Licensee will complete all documentation for each infant on the Infant Sleeping Plan.

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: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5