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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405824
Report Date: 08/04/2023
Date Signed: 08/04/2023 05:01:07 PM


Document Has Been Signed on 08/04/2023 05:01 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:KUZINA, ELENAFACILITY NUMBER:
073405824
ADMINISTRATOR:KUZINA, ELENAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 671-2915
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:14CENSUS: 11DATE:
08/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:ELENA KUZINATIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst Tasha Alexander met with licensee Elena Kuzina for an unannounced 1 YEAR/REQUIRED inspection. Present for today's inspection is licensee, assistant Tatian Voronina and 11 children in care, consisting of 4 infants (over 12 months) and 7 preschoolers.. LPA toured the facility for a health and safety inspection. The children's files were reviewed. There is a fully charged 3A40BC fire extinguisher, a working smoke alarm, and working carbon monoxide detector in the home. All were inspected/tested and found to be in working condition. There is a working telephone in the home, no change in the phone number. Per licensee there are no fire arms on the premises. There is a swimming pools located in the backyard that has a 5 ft iron fence with a self latching gate that swings away from the pool. All poisons, cleaning solutions and medications are inaccessible to children in care. Licensee and her husband have current CPR & 1st AID cards which expire 1/2025 respectively. THE OFF LIMITS AREA ARE: the master bedroom/bath, 2nd bedroom, and garage. These areas will be inaccessible to children in care by closed and/or locked doors and visual supervision. THE ON LIMIT AREAS ARE: Dining room, Playroom, 1st Bedroom, hall bathroom and backyard. Licensee was reminded that baby walkers, excersaucers and baby bouncers are not allowed. 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: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: KUZINA, ELENA
FACILITY NUMBER: 073405824
VISIT DATE: 08/04/2023
NARRATIVE
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A review of staff records on 8/1/23 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 licensee and assistant both have immunization records are in file. Both have declined the flu vaccines.

Today the mandatory mandated reporter training course was also discussed. Licensee and assistants' certificates are expired.

Infant Safe Sleep practices were discussed. Licensee is not currently caring for infants 12 months or under. A copy of the Individual Infant Sleep Plan (LIC 9227) and a of the Infant Sleep Chart/log was given and explained to licensee today. Licensee is reminded that she must phyiscally check ALL napping infants every 15 minutes and document on the log provided.

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

CONTINUED ON 809-C

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

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: KUZINA, ELENA
FACILITY NUMBER: 073405824
VISIT DATE: 08/04/2023
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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 ATTACHED 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: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/04/2023 05:01 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: KUZINA, ELENA
FACILITY NUMBER: 073405824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023

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. TODAY BOTH LICENSEE AND ASSISTANT'S CERTIFICATES ARE EXPIRED
POC Due Date: 08/18/2023
Plan of Correction
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LICENSEE , ASSISTANT WILL UPDATE THEIR MANDATED REPORTER TRAINING AND SUBMIT THE UPDATED CERTIFICATES TO COMMUNITY CARE LICENSING BY 8/18/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5