197410009-12-14-2022-58-CC-SORS-CM4RWT-20221214122339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197410009
Report Date: 12/14/2022
Date Signed: 12/14/2022 12:23:53 PM

Document Has Been Signed on 12/14/2022 12:23 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	ZIYALOVA FAMILY CHILD CARE		FACILITY NUMBER:	197410009
ADMINISTRATOR:	ZIYALOVA, KARINE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 376-0975
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	14	CENSUS: 7	DATE:	12/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:37 AM
MET WITH:	ZIYALOVA, KARINE- Licensee		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/14/2022 Licensing Program Analyst (LPA), Suzette Ornelas conducted an unannounced Annual Required Inspection and was met by Licensee, Karine Ziyalova. Also present was Licensees Husband, Assistant and Speech Therapist from ERA Behavioral Solutions. Days and hours of operation are Monday through Friday 7a-5:30p. LPA toured the home inside and outside and a census was taken. LPA observed 7 children (no infants). Current facility sketch reviewed and all areas identified on the facility sketch were inspected. Family members residing at facility are: licensee and her husband. Licensee's home is a single story dwelling with 3 bedrooms and, 2 bathrooms. Two bedrooms in the home are on limits and are used for child care and napping. Licensee also has a two story two bedroom, one bathroom back house in the back yard. The first floor of the back house is used as an activity room, there is a study room and a play room. Child care is provided mainly in the two bedrooms of the home and in the 1st floor of the back house. Children in care have access to the bathroom located in the hallway near their play/bedrooms where care is being provided and to the bathroom in the back house. Children eat in the back house. The second floor of the back house is OFF-LIMITS to the children in care. Licensee has made the kitchen and the second floor of the back house inaccessible by placing a gate in the doorway between the kitchen and play room. All other rooms are off-limits and made inaccessible by use of locked doors and supervision. Children have access to the back yard and patio for activities. There is a jacuzzi in the back yard that is fully fenced with a 5 feet rod iron fence with two gates open away from the Jacuzzi area and self- close and self -latch. The jacuzzi is equipped with a cover. The Fire Extinguishers (2A-10-BC) is mounted on the wall in the bedroom of the front house and in the kitchen of the back house. There is a working smoke/carbon monoxide detectors located in the living room and in the kitchen in the back house.The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. The First Aid kit was observed and complete.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette Ornelas	TELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

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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Document Has Been Signed on 12/14/2022 12:23 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ZIYALOVA FAMILY CHILD CARE	FACILITY NUMBER: 197410009
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2022

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
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 persons did not have current Mandated reporter training certificate which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/06/2023
	Plan of Correction
1 2 3 4	LIcensee will provide proof of completion to LPA via mail/email.

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
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 persons did not have proof of current MMR, Tdap immunizations which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/06/2023
	Plan of Correction
1 2 3 4	LIcensee will provide proof of immunization records to LPA via mail/email.

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: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette Ornelas	TELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/14/2022 12:23 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ZIYALOVA FAMILY CHILD CARE	FACILITY NUMBER: 197410009
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(a)

Immunizations

(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in 4 out of 5 children did not have proof of current immunization records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/06/2023
	Plan of Correction
1 2 3 4	LIcensee will provide proof of immunization records to LPA via mail/email.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette Ornelas	TELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ZIYALOVA FAMILY CHILD CARE	FACILITY NUMBER: 197410009
	VISIT DATE: 12/14/2022

NARRATIVE

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Per LIS the facility annual fees are current. The facility roster was observed, and current. There are age appropriate toys and napping equipment on the premises. Licensee has posted as required the License, and all other required postings in a visible location. There are no firearms or ammunition on the premises. There are no fireplaces or open face heaters in the home .An emergency fire/disaster drill has been completed and documented within the last 6 months.

There are currently 0 infants in care. LPA discussed Safe Sleep Regulations with licensee and provided a copy of the Infant Safe Sleep Regulation, a sample of an infant safe sleep log, a copy of the LIC 9227, and Frequently Asked Questions regarding Infant Safe Sleep packet. Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. The outdoor play area in the backyard is fenced and there are no hazards to children present. LPA discussed the importance of ensuring that equipment is regularly inspected, dusted off as needed and removed if broken.

Capacity as specified on the license is being maintained. LPA reviewed 5 children's records and observed records were incomplete. Licensee will obtain 4 out of 5 children immunization records and provide proof to LPA via mail/email. Licensee’s pediatric CPR/First Aid is current. Licensee and Assistants Mandated Reporter Training in not current, LPA provided information regarding the Mandated Reported Training regulation and the requirement to complete every two years. Licensee and Assistant will complete the required Mandated Reporter Training (AB1207) and submit proof of completion certificate to LPA via mail/email. A review of records indicates that all employees and/or volunteers do not have immunization records on file for pertussis and measles. LPA provided information regarding the Required Immunization regulation. Licensee and Assistant will obtain proof of immunizations and submit proof to LPA via mail/email. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette Ornelas	TELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: ZIYALOVA FAMILY CHILD CARE	FACILITY NUMBER: 197410009
	VISIT DATE: 12/14/2022

NARRATIVE

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LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, 3 Type B deficiencies are cited.

Type B: 1596.8662(b)(1)
Type B: 1597.622(c)
Type B: 102418(a)

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

suzette.ornelas@dss.ca.gov

SUPERVISOR'S NAME: Lisa Rios	TELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette Ornelas	TELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022

LIC809 (FAS) - (06/04)

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