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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423402
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:42:02 PM


Document Has Been Signed on 10/27/2022 02:42 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:LOKTEVA, OXANAFACILITY NUMBER:
013423402
ADMINISTRATOR:LOKTEVA, OXANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 283-1914
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:14CENSUS: 12DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Licensee Oxana LoktevaTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Jyoti Saini met with Licensee, Lokteva Oxana for an unannounced Annual Random Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the staff. Licensee arrived during the inspection. Present during this inspection was Licensee and 2 helpers supervising 12 preschoolers. Licensee is within capacity limits of a Large License. Licensee lives in the home with her husband and two children. The home is a single home with 3 bedrooms, 2 bathrooms, living room, kitchen, dining room, garage, and back yard. The hours of operation are 8:00AM- 6:00PM, Monday -Friday. The facility has liability insurance through DCI company.
ON-LIMIT AREAS: living room, (main play area) the dining room, the master bedroom (nap room)and the bathroom located at the end of the hallway and backyard.

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

LPA observed the following: Daycare Area is clean, orderly, and equipped with age appropriate toys and equipment for children, indoors and outdoors. Home has a working telephone, a working smoke and carbon monoxide detector, and a fire extinguisher that meets the minimum requirements. There are no bodies of water in the day care. The Fireplace in the Daycare area is screened. There are child size tables and chairs for snack and activities. There are ample of age appropriate toys that appear to be safe and in good condition. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection. The napping room had cots in good condition and each child have their separate blankets. The outdoor play area is fenced, has adequate shade with cushioning under the play structure. LPA inspected the swing set that is securely bolted to the ground. The Licensee has a trampoline in the backyard. LPA advised her that she must comply with the manufacturer instructions listed on the trampoline, including supervision requirements, if any of the day care children use the trampoline. Licensee states there are no guns or weapons of any kind in the home.

Licensee and helper’s CPR expire in 04/2024. Licensee provides daily snacks and meals. Discipline policy is redirection. LPA reviewed children’s files. All the files are complete and up to date. All required postings are properly posted.

see next page...

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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 3


Document Has Been Signed on 10/27/2022 02:42 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: LOKTEVA, OXANA
FACILITY NUMBER: 013423402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

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. The review of drill log indicates that the last drill was conducted 12/07/2021. This poses a potential health and safety risk to children in care.
POC Due Date: 10/31/2022
Plan of Correction
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 Licensee shall submit proof of correction by the aforementioned date. Failure to follow through with this plan of correction will result in a civil penalty of $100 per day until corrected.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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. LPA osberved that S1 does not have required immunization (influenza, pertussis, and measles) on the file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2022
Plan of Correction
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Licensee shall obtain immunization records for her helper and submit copies of documenation to LPA by the POC due date.

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: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3


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: 10/27/2022
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During Inspection, 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.

LPA discussed the safe sleep regulations with licensee 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. LPA 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 about Mandated Reporter training available on CCLD website. Training must be completed every 2 years. Training can be taken online at www.mandatedreporterca.com

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/inspection-process.

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

See attached 809-D for deficiency cited today.

Exit interview conducted and report was reviewed with the licensee Oxanan Lokteva.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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