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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407669
Report Date: 08/04/2023
Date Signed: 08/04/2023 01:44:35 PM

Document Has Been Signed on 08/04/2023 01:44 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:NIKITOVA, ANNAFACILITY NUMBER:
073407669
ADMINISTRATOR:NIKITOVA, ANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 533-8767
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
08/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:ANNA NIKITOVATIME COMPLETED:
02:00 PM
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Licensing Program Analyst Tasha Alexander met with licensees Anna Nikitova for an unannounced 1 YEAR/REQUIRED inspection. Present for today's inspection is licensee, 2 assistants Yana Yevstratova, ana lavrishik and 7 children in care, consisting of 2 infants (over 12 months) and 5 preschoolers.. LPA toured the facility for a health and safety inspection. The children's files were reviewed. There is a fully charged 2A10BC fire extinguisher, a working smoke alarm/carbon monoxide detector combo 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 are no swimming pools, hot tubs or other bodies of water located on the premises. All poisons, cleaning solutions and medications are inaccessible to children in care. Licensee and assistants have current CPR & 1st AID cards which expire 11/2024 respectively. The off-limits areas are: the master bedroom/bath, 2nd bedroom/office, 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: Living room, Kitchen, Play room, 1st Bedroom, hallway 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.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
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)
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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: NIKITOVA, ANNA
FACILITY NUMBER: 073407669
VISIT DATE: 08/04/2023
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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 both assistants have immunization records are in file. Licensee and assistants have declined the flu vaccines.

Today the mandatory mandated reporter training course was also discussed. Licensee and both assistants' certificates are up to date.

Infant Safe Sleep practices were discussed. Licensee is not currently caring for infants 12 months or under. Licensee does keep a sleep log for all infants in care.

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

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
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)
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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: NIKITOVA, ANNA
FACILITY NUMBER: 073407669
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.

AS A RESULT OF TODAY'S INSPECTION, THERE ARE NO DEFICIENCIES CITED TODAY.

An exit interview was conducted. A notice of site visit was posted.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
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)
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