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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407669
Report Date: 02/03/2020
Date Signed: 02/03/2020 01:20:40 PM

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:14CENSUS: 9DATE:
02/03/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Anna NikitovaTIME COMPLETED:
01:30 PM
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On 02/03/2020 at 9:20 AM Licensing Program Analyst (LPAs) Monica Mathur and Arminder Singh conducted an unannounced Annual/Random Inspection at Anna Nikitova's Family Day Care Home. LPAs met with Licensee, Anna Nikitova and explained the purpose of today’s inspection. Present in the home were Licensee, 2 Assistants and nine (9) day care children (1 infant, 8 preschool age). Facility is in compliance with required ratios/capacity today. Children were engaged in various activities under the supervision of the Licensee and Assistants. Days and hours of operation are Monday - Friday from 7:30 AM - 5:30 PM. Adults over the age of 18 and residing in the home are the Licensee and Licensee's spouse. All adults have Criminal Background Check Clearances. Licensee stated her spouse moved into the home in December 2019. She will submit his TB clearance. She submitted signed Criminal Record Statement LIC508 during inspection today. Present in the home also was adult nephew who is visiting for 10 days.

At 9:30 AM LPAs toured the indoor and outdoor areas of the home during today's inspection:
INDOOR SPACE: In Use Areas: Living room, Kitchen, Play room, Bedroom 1 and Bathroom across the hallway from the in-use bedroom. Off Limit Areas: Master bedroom, Master bathroom, Bedroom 2, Garage.
The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children in the home. Furniture and equipment, such as cribs, mats, feeding chairs, and tables were age appropriate and in good condition. There were no baby walkers or bouncers observed on the premise during today’s inspection. The home is orderly, and safe for the day care children. LPA did not observe any wall heaters in the home. There is a barricaded fireplace in the Living room. There are no stairs inside the home. LPAs observed cleaning supplies (Windex spray, Comet powder) in the in-use bathroom cabinet under the sink that did not have a latch or lock; and was easily accessible to the children. During LPAs inspection, all children used the bathroom.

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SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 725-5998
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2020
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: NIKITOVA, ANNA
FACILITY NUMBER: 073407669
VISIT DATE: 02/03/2020
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OUTDOOR SPACE: In Use Areas: Covered patio area, Yard behind Off Limit Areas: Right side yard, Storage shed. The outdoor space and play equipment were observed to be maintained in safe condition and free of hazards. The yard was fenced and there were no bodies of water.

LPA observed a fully charged 2A10BC fire extinguisher in the kitchen and working smoke / carbon monoxide detectors. The Licensee states that she does not have any weapons or pets in the home. LPA reviewed a current Children Roster and obtained a copy. Last fire/disaster drill was completed on 12/18/19. All required postings including but not limited to Parent Rights Poster, Facility License, Emergency Disaster Plan were observed posted on a wall in the Entrance area. The Licensee states that she does not transport children. Licensee states that she supplies snacks and meals to the children. Food storage area was observed to be sanitary and safe. LPA discussed Healthy Beverages Act with the Licensee. Day care home appeared to be free of flies, other insects, and rodents during today’s inspection.

FILE REVIEW:
At 10:00 AM Children's files were reviewed and contained all required Licensing forms and records including but not limited to Receipt for Parents' Rights, Immunization record, Identification & Emergency Information, Consent for Medical Treatment, Health History. Licensee does not have Landlord/Owner Consent for Additional Children LIC 9149 or Parent Notification for Additional Children LIC 9150 in care. Licensee states she is not aware of these requirements. Per Licensee, 15 children are currently enrolled in the day care.
Licensee and Assistant files contained Criminal Record and Child Abuse Index Clearance, TB clearance, Immunizations for Measles, Pertussis, Flu and required Mandated Reporter Training per AB1207. Licensee's certifications for CPR and First Aid are current and expire on 10/2020. Assistants files do not contain Statement Acknowledging Requirement to Report Suspected Child Abuse LIC 9108, Employee Rights LIC9052,

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during 80% of the operating hours of the day care and ensure that the children are supervised at all times. The Licensee understands her capacity options and that she cannot have more than 8 children in the home at any time without at least two qualified adults present. Licensee also understands that she must comply with the ratio and capacity requirements of the Small Family Child Care Home license whenever she or a qualified adult is alone with the children.
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SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 725-5998
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2020
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: NIKITOVA, ANNA
FACILITY NUMBER: 073407669
VISIT DATE: 02/03/2020
NARRATIVE
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LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who comes in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period.

LPA advised the Licensee of the required Mandated Reporter Training for Child Care Providers that all Licensees and employees are required to complete as of January 1, 2018. The website for the online training is: http://www.mandatedreporterca.com/training/childcare.htm.

Incidental Medical Services (IMS) policy was discussed. The Licensee stated that she currently has one child in care who requires IMS. There is an approved IMS Plan on file at Licensing Regional Office. 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

Beginning January 1, 2019 AB 2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA provided a copy of the “Lead Poisoning Facts Information Flyer” and “Safe Sleep Information Flyer” to Licensee.

In the areas that were evaluated, regulatory violations were observed.
At 12:30 PM exit Interview was conducted, where this report, the citations, plan of corrections, and appeal rights were reviewed and discussed with Licensee. Citations are issued on 809-D pages of this report. Licensee signed the report acknowledging receipt of documents. LPA reminded Licensee that failure to correct deficiencies by Plan of Correction Due Date may result in penalties of $100 per day per violation.
Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to the parent of new children enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file. Fact Sheet AB 633 was also provided.

Licensee agreed to submit the following by 02/10/2020:
- Updated Sketch showing Storage Shed by 02/10/2020
- Emergency Disaster Plan LIC 610A by 02/10/2020
- Spouse's TB Clearance by 03/03/2020

A NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED NEAR THE FRONT ENTRANCE TO THE HOME FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 725-5998
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2020
LIC809 (FAS) - (06/04)
Page: 3 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: NIKITOVA, ANNA
FACILITY NUMBER: 073407669
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2020
Section Cited

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102417: Operation of a Family Child Care Home: (g) The home shall be free from defects or conditions which might endanger a child (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. This requirement is not met as evidenced by:
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Per LPAs inspection cleaning supplies/poisons (Windex, Comet) was stored in unlocked cabinet under the in-use bathroom sink. This poses an immediate risk to the health and safety of children in care.
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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: Sherelle JohnsonTELEPHONE: (510) 725-5998
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2020
LIC809 (FAS) - (06/04)
Page: 4 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: NIKITOVA, ANNA
FACILITY NUMBER: 073407669
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2020
Section Cited

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102416.1 Personnel Records: Personnel records shall be maintained on each employee. This requirement is not met as evidenced by:
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Per LPA's review of personnel files, Assistants 1, 2, 3 do not have Employee Rights LIC9052 and Statement Acknowledging Requirement to Report Child Abuse LIC9108. This poses a potential risk to the health and safety of children in care.
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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: Sherelle JohnsonTELEPHONE: (510) 725-5998
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2020
LIC809 (FAS) - (06/04)
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