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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408819
Report Date: 04/26/2019
Date Signed: 04/26/2019 01:43:31 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:BELINSKAYA, IRINAFACILITY NUMBER:
073408819
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
04/26/2019
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Belinskaya, Irina, ApplicantTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA), Redmond conducted a Pre-Licensing, inspection visit. During the inspection, LPA met with Irina Belinskaya, Applicant and Ms. Belinskaya’s friend.

Purpose of Inspection: The purpose of the inspection is for the LPA to conduct a physical inspection of the facility to ensure that the facility is safe and that the Applicant met each of the requirements to be issued a License for a Family Day Care.

Right to Inspect Authority: LPA discussed with Applicant:

All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

Accessible (On Limit) areas to children include:

The Applicant has designated the following areas as accessible to children in care. These areas shall be marked on the Facility Sketch as “On Limit” and are subject to inspection by Licensing authority. LPA inspected accessible areas of the facility and made the following observations on this date:

§ Classroom – ample toys, equipment and materials

§ Hall – no visible hazards

§ Restroom – working toilet and sink, sanitary items, no cleaning solutions, or other toxins

§ Play yard – enclosed by gate, adequate toys, equipment and play structures

§ Office – to be used as a sleep area (for infants) - CONTINUED

SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen RedmondTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2019
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: BELINSKAYA, IRINA
FACILITY NUMBER: 073408819
VISIT DATE: 04/26/2019
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Inaccessible (Off Limit) areas to children include:

The Applicant has designated the following areas as inaccessible to children in care. These areas are typically not inspected unless, the Department has reason to believe the health and safety of a child is at risk, at which time, the representative has the authority to inspect areas designated as inaccessible. These areas shall be marked on the Facility Sketch as “Off Limit”:

§ Kitchen cabinets – a gate/barricade is required because children must past the kitchen to get to the restroom

§ Living room – a gate/barricade is required because children must past the living room to get to the restroom

§ Private Bedrooms – install a safety knob/device preventing access to children because of proximity to restroom

§ Office - install a safety knob/device preventing access to children because of proximity to restroom

Health and Safety: LPA observed and or verified that the following requirements were met:



§ All adults have criminal background clearances and are associated to the facility

§ Licensee has current pediatric CPR/First Aid

§ Licensee has current immunization's

§ The facility is clean and orderly

§ Fire Extinguisher: LPA observed a fire extinguisher, located in the closet in the classroom area. Classification, 2A-10BC which was fully charged meets State Fire Marshall standards and must be serviced annually or as often as necessary.

§ Smoke and Carbon monoxide (combination) detector: LPA tested and found the alarm was operable. Alarm should be tested and batteries replaced, regularly as required.

CONTINUED

SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen RedmondTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2019
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: BELINSKAYA, IRINA
FACILITY NUMBER: 073408819
VISIT DATE: 04/26/2019
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Reporting:

LPA discussed with Applicant the following situations must be reported and or communicated with the Licensing agency including:

Changes to the Facility: Such as the facility being relocated, construction, remodeling, telephone number changes and/or if you move from your home should be reported to the Department before or as soon as they occur.

§ Employee/Adults: All adults in the home and or who have access to the children shall have a live scan and receive a *criminal background clearance (receive an exemption if required) and be associated to the facility. A Criminal Record Statement shall be kept on file.

*Criminal Record Clearance: Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearance, prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

§ LPA advised the applicant how to access forms, regulations, training videos and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov



§ Abuse – Licensee and staff are Mandated Reporters and are required to report to CCLD/Licensing: physical injury, sexual abuse, neglect, willful harming, endangering or injury, unlawful corporal punishment or injury.

§ Incidents/Injuries: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. LPA provided and went over required reporting form.

Training/Ongoing Requirements



§ Training Videos, forms and regulations are available on the CCLD website www.ccld.ca.gov -

CONTINUED

SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen RedmondTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2019
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: BELINSKAYA, IRINA
FACILITY NUMBER: 073408819
VISIT DATE: 04/26/2019
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List of Forms Required for Family Child Care Homes


These forms can be accessed online at: www.ccld.ca.gov


Form Numbers

§ Affidavit Regarding Liability Insurance - LIC 282
§ Consent for Emergency Medical Treatment - LIC 627
§ Family Child Care Consumer Guide - PUB 72
§ Identification and Emergency Information - LIC 700
§ Immunization record – Blue Card
§ Notification of Parent’s Rights - LIC 995A
§ Parent Notification Additional Children in Care - LIC 9150

Facility Records

§ Child Care Facility Roster - LIC 9040
§ Employee Rights - LIC9052
§ Statement Acknowledging Requirement to Report Child Abuse - LIC9108
§ Unusual Incident/Injury Report - LIC 624B

Documents Required to be Posted

§ Emergency Disaster Plan - LIC6101A
§ Facility License - LIC203
§ Disaster Drills – Earthquake/Fire – Required Every six (6 months) – May use own form
§ Notification of Parents Rights Poster - PUB394
§ “If You See Something, Say Something” - Poster

- CONTINUED
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen RedmondTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2019
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: BELINSKAYA, IRINA
FACILITY NUMBER: 073408819
VISIT DATE: 04/26/2019
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 Fire and safety drills must be performed every six months and documented for review by the Department. – must be posted in plain view of parents

· Supervision: Licensee shall be present in the home and shall ensure children in care are supervised at all times. When temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise children in Licensee’s absence. Children shall not be left in parked vehicles.

§ CPR & Pediatric First Aid Certification: In the absence of the Applicant, a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance and is associated to the facility license.

· Mandated Reporter of Child Abuse: Applicant and staff are mandatory reporters. As such, they are required to report: physical injury, sexual abuse, neglect, willful harming, endangering or injury, unlawful corporal punishment or injury. Online training can be found at: www.mandatedreporterca.com.



· NEW Infant Safe Sleep Laws 2019. Applicant was provided Safe Sleep booklet, brochure and other resource information and LPA went over safe sleep requirements. http://www.cdss.ca.gov/inforesources/Child-Care-Licensing/Public-Information-and-Resources/Safe-Sleep

§ Smoking: is prohibited in a Family Child Care home.

§ Equipment: Saucer chairs, bouncers, walkers, or any similar items are prohibited, a hand out was provided.

· Updates: Licensees may register to receive child care updates and PINS: childcareadvocatesprogram@dss.ca.gov

· Resource and Referral Agencies: https://www.ccrcca.org/resources/family-resource-directory/item/california-child-care-resource-referral-network
CONTINUED
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen RedmondTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2019
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: BELINSKAYA, IRINA
FACILITY NUMBER: 073408819
VISIT DATE: 04/26/2019
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LICENSING STATUS


CONGRATULATIONS

LPA has determined that Applicant has met the requirements to be granted a License as a Licensee of a Family Day Care Center. Applicant's request for a License has been - APPROVED.

A license will be issued and mailed to Licensee. Licensee is responsible for being informed of new and existing licensing regulations and remain in compliance. LPA conducted an exit interview. LPA issued a Facility Evaluation Report and the Licensee signed the report. A copy of this report must remain on file for 3 years and produced upon request.
CONCLUSION OF REPORT
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen RedmondTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2019
LIC809 (FAS) - (06/04)
Page: 7 of 7
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: BELINSKAYA, IRINA
FACILITY NUMBER: 073408819
VISIT DATE: 04/26/2019
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§All poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children are made inaccessible to children in care. – Requirement met.

§ There are no pools, spas, hot tubs, fish ponds or other bodies of water accessible to children.

§ There is a fire place, which is enclosed by a gate.

§ Comfortable temperature, adequate ventilation

§ Safe and adequate toys, play equipment and materials

§ No firearms

§ Cots

· A landline will be used for telephone service


LPA Visits/Assistance:



LPA discussed the types of Licensing visits and reporting with Applicant:

Visits: LPA provided an overview of various types of visits and other interactions the Applicant can expect to receive from the Department including: Annual, Plan of Correction, Case Management, Complaint Investigations



Assistance from LPA/CCLD: LPA explained how to obtain assistance from her LPA and what information is needed when submitting documentation or requesting assistance from the CCLD office. Always provide facility license number. LPA provided resources to the CCLD website. www.ccld.ca.gov


SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Geneen RedmondTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2019
LIC809 (FAS) - (06/04)
Page: 3 of 7