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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073403875
Report Date: 10/26/2022
Date Signed: 10/26/2022 04:22:19 PM


Document Has Been Signed on 10/26/2022 04:22 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:WCISLO, LUCYNA & JANUSZFACILITY NUMBER:
073403875
ADMINISTRATOR:WCISLO, LUCYNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
9254700977
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:14CENSUS: 8DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:LUCYNA WCISLOTIME COMPLETED:
04:45 PM
NARRATIVE
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  1. 1:45pm- Licensing Program Analyst Tasha Alexander met with licensee Lucyna Wcislo for an unannounced 1 YEAR REQUIRED inspection. Present for the inspection were licensee, her fully finger printed adult assistant Izabela Sadowska and 8 children in care consisting of 2 infants and 6 preschoolers. LPA toured the facility and back yard for a health and safety inspection. The children's files and staff file were reviewed. The home is equipped with a fully charged 2A10BC fire extinguisher, working smoke detector, and working carbon monoxide detector. There is a working telephone in the home, no change in phone number. Per licensee there are no fire arms on the premises. There is a swimming pool located in the backyard that is surrounded by a California State Fire Marshall approved 5 foot iron fence with a self latching gate that swings away from the pool. All poisons, cleaning solutions and medications are inaccessible to children. Both licensees have current CPR and 1st Aid training cards which expire 8/2024 respectively. The off limits areas are all bedrooms and kitchen. These areas will be inaccessible to children by closed and/or locked doors, safety gates and visual supervision. Licensee was also informed of the licensing web address (www.ccld.ca.gov) for downloading child care forms and (www.myccl.com) to register to receive child care updates.
Licensee [or facility representative] 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.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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: WCISLO, LUCYNA & JANUSZ
FACILITY NUMBER: 073403875
VISIT DATE: 10/26/2022
NARRATIVE
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A review of staff records on 10/25/22 indicates that all facility staff or other individual who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Effective September 1, 2016, a person may not work or volunteer at a child care center or family child care home unless he or she has been vaccinated against pertussis, measles and influenza or has an exemption. Today, licensees have immunization records in file. Assistant is missing proof of mmr/TB today.

Today the newly implemented mandatory mandated reporter training course has also been discussed. Both licensees have up to date certificates in file. Assistant does not have certificate in file today.


CONTINUED ON 809-C


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
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
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: WCISLO, LUCYNA & JANUSZ
FACILITY NUMBER: 073403875
VISIT DATE: 10/26/2022
NARRATIVE
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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.

PLEASE SEE 809-D FOR CITATION



An exit interview was conducted. A notice of site visit was posted.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/26/2022 04:22 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: WCISLO, LUCYNA & JANUSZ

FACILITY NUMBER: 073403875

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. THIS REQUIREMENT IS NOT MET AS EVIDENCED BY: TODAY ASSISTANT IZABELA SADOWSKA DOES NOT HAVE THE MANDATED REPORTER CERTIFICATES IN FILE
POC Due Date: 11/09/2022
Plan of Correction
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LICENSEE WILL HAVE HER ASSISTANT COMPLETE THE MANDATED REPORTER TRAINING FOR CHILDCARE PROVIDERS AND SUBMIT BOTH CERTIFICATES TO COMMLUNITY CARE LICENSING BY 11/9/22 (CHILDCARE PROVIDERS & GENERAL)
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) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. THIS REQUIREMENT IS NOT MET AS EVIDENCED BY : A REVIEW OF RECORDS REVEALED THAT ASSISTANT IZABELA SADOWSKA DOES NOT HAVE PROOF OF TB TEST RESULTS IN FILE TODAY
POC Due Date: 11/09/2022
Plan of Correction
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LICENSEE WILL HAVE HER ASSISTANT OBTAIN AND SUBMIT PROOF OF TB TEST RESULTS BY 11/9/22. TEST SHOULD BE NO MORE THAN ONE YEAR OLD.

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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 10/26/2022 04:22 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: WCISLO, LUCYNA & JANUSZ

FACILITY NUMBER: 073403875

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. THIS REQUIREMENT IS NOT MET AS EVIDENCED BY : A REVIEW OF RECORDS REVEALED THAT ASSISTANT IZABELA SADOWSKA DOES NOT HAVE PROOF OF MEASLES VACCINE IN FILE TODAY
POC Due Date: 11/09/2022
Plan of Correction
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LICENSEE WILL HAVE HER ASSISTANT OBTAIN PROOF OF MEASLES VACCINATION AND SUBMIT A COPY TO COMMUNITY CARE LICENSING BY 11/9/22
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. THIS REQUIREMENT IS NOT MET AS EVIDENCED BY: TODAY THERE ARE SEVERAL CHILDREN WITH IMMUNIZATION BLUE CARDS IN FILE THAT ARE NOT UP TO DATE
POC Due Date: 11/09/2022
Plan of Correction
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LICENSEE WILL HAVE EACH CHILD'S PARENT SUBMIT A COPY OF THEIR CHILD'S UPDATED IMMUNIZATION RECORDS. LICENSEE WILL UPDATE THEIR CHILD'S BLUE CARDS AND SUBMIT A COPY TO COMMUNITY CARE LICENSING BY 11/9/22

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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
LIC809 (FAS) - (06/04)
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