<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423402
Report Date: 11/09/2021
Date Signed: 11/09/2021 11:00:17 AM

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:LOKTEVA, OXANAFACILITY NUMBER:
013423402
ADMINISTRATOR:LOKTEVA, OXANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 283-1914
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:14CENSUS: 7DATE:
11/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Oxana LoktevaTIME COMPLETED:
11:15 AM
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
On 11/9/2021 at 9:00am Licensing Program Analyst (LPA) Jaylena Miller, met with licensee Oxana Lokteva for an UNANNOUNCED ANNUAL REQUIRED INSPECTION. Present for the inspection were fingerprint cleared and associated assistant and adult son and 7 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 8:00am-6:00pm

The home is a single home with 3 bedrooms, 2 bathrooms, living room, kitchen, dining room, garage and back yard. LPA observed the home to be neat and clean with central heating and ventilation for safety and comfort.

The OFF-LIMIT AREAS are Bedrooms #1 and #2 and the garage, and will be inaccessible to children by locked doors, safety gates and visual supervision.

The ON-LIMIT AREAS are the living room, which is used as the main daycare area, the dining room, the master bedroom that is used as a nap room and the bathroom located at the end of the hallway. The designated isolation area will be the couch in the dining area. The backyard will be a designated outdoor play area that is fully fenced. The outdoor area has age appropriate toys and furnishings that LPA observed to be clean and free from defects and dangerous conditions. LPA inspected the swing set that is securely bolted to the ground and the swings can hold LPA Miller’s weight.

All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged fire extinguisher 2A-10-BC located in the hallway that leads to the garage, working smoke detector, carbon monoxide that is located in the hallway between bedrooms #1 and #2, 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 completed the Health and Safety training on 2/17/2018, CPR/First Aid is current and expires on 2/22/2022. The licensee is in complaint with the immunization laws and has completed the mandated reporter training on 1/23/2021.

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: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LOKTEVA, OXANA
FACILITY NUMBER: 013423402
VISIT DATE: 11/09/2021
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
At 9:45am am LPA Miller reviewed 12 children’s files, facility and staff files and documented on LIC 857 and LIC 859 respectfully. There is a current roster available for review and copy obtained. Staff interview also conducted and documented.

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.

Licensee was reminded of the responsibility as a mandated reporter and the training's 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.

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.

There are no deficiencies cited today however LPA did provide technical assistance on the mask mandate indoors for childcare providers. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Oxana Lokteva.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jaylena MillerTELEPHONE: (510) 292-8297
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2