197414648-10-26-2023-58-CC-KCHE-CWYVM4-20231026163256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197414648
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:33:12 PM

Document Has Been Signed on 10/26/2023 04:33 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:	TSINMAN & SUSTRETOVIENE FAMILY CHILD CARE		FACILITY NUMBER:	197414648
ADMINISTRATOR:	TSINMAN, SIMONA & ILONA S.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 823-0111
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90046
CAPACITY:	14	CENSUS: 6	DATE:	10/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Facility Representative (FR)		TIME COMPLETED:	05:00 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 10/26/2023 at 2:40 PM, Licensing Program Analyst (LPA)Katrina Chicote conducted an Unannounced Required – 1 Year inspection to the above facility. LPA observed advertising posted on fence in front of home with facility # posted. Upon arrival, LPA disclosed the purpose of the inspection and met with Anna Kuloyan, Facility Representative (FR), who allowed entry to facility. Per FR, Licensee is currently not home. LPA singularly toured facility. Adults in the home were discussed and all have criminal record clearance. There were six day care children present during today’s inspection, which includes two infants. FR states that there are currently eight children enrolled. The children's roster was reviewed and is current. LPA provided LIC 126 during inspection. LPA observed license posted and discussed other posting requirements. Disaster drill log was also available during today’s inspection, last disaster drill conducted on 10/13/2023. This is a single story home which consists of Day Care Room 1(located upon entry of the home), Day Care Room 2(located next to Day Care Room 2), Day Care Room 3 (located down hallway to the left), Kitchen located through doorway in Day Care Room 2), and Bathroom 1 (located down hallway next to Day Care room 3). Facility is part of duplex property with other property separate address (1300 N. Poinsettia Pl.) that is also a licensed family child care home (#197407376). LPA observed Bedroom 1 through double doors in Day Care Room 3, LPA observed bed and television in this room. LPA did not observe any off limits areas to facility at time of inspection. All areas identified by FR as accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for the safety of the children. There is a working telephone maintained in the home. At 2:45 PM, LPA observed Day Care Room 1 to have four cribs and two pack-n-plays placed against wall not blocking walkways and entrances/exits and bins with a variety of age appropriate toys available for children free of loose and sharp parts. At 2:47 PM, LPA observed Day Care Room 2 to have three infant high chairs, book shelf filled with art materials, and child size tables and chairs available for children well Report Continues - Page 1 of 4

SUPERVISOR'S NAME: Denise Gibbs	TELEPHONE: (323) 558-2794
LICENSING EVALUATOR NAME: Katrina Chicote	TELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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 10

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: TSINMAN & SUSTRETOVIENE FAMILY CHILD CARE	FACILITY NUMBER: 197414648
	VISIT DATE: 10/26/2023

NARRATIVE

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maintained. Per FR, they provide food for children in care and use Day Care Room 2 for eating. At 2:50 PM, LPA observed Kitchen to be free of clutter and observed low cabinets and drawers to be free of hazards at time of inspection. LPA observed child safety locks available on low cabinets and drawers. At 2:53 PM, LPA observed Day Car Room 3, to be used for napping of preschool children and children transitioning out of nap time during inspection. LPA observed soft mats laid out in Day Care Room each with own fitted sheet. At 2:57 PM, LPA observed bathroom to have operable equipment and adequate supplies at time of inspection. At 2:58 PM, LPA observed under cabinet sink in bathroom to not have child safety lock have cleaning solutions such as Lysol Disinfectant spray, glass cleaner, Woolite Carpet & Upholestry cleaner, and unlabeled cleaning solution that FR identified as floor cleaner to be accessible to children in care at time of inspection. LPA observed children using bathroom independently at time of inspection. LPA discussed observation with FR and LPA observed FR move items to up high shelf making it inaccessible to children in care at time of inspection. FR was advised that inaccessibility of hazards must be constantly reassessed depending on the age of children in care.

Per FR, the children will have access to side yard for outdoor play. At 3:00 PM, LPA observed side yard has concrete flooring maintained and adequate perimeter fencing through-out the yard. LPA observed variety of plastic play houses in outdoor play area that is well maintained at time of inspection.

LPA did not observe any pets at time of inspection and FR confirms she has no pets. Per FR, there are no weapons, firearms in the home and there are no bodies of water around the premises. LPA observation did not see any bodies of water around the premises or firearms/weapons at time of inspection.

At 2:52 PM, the valve on the larger than required 2A-10BC fire extinguisher indicates fully charged but with no proof of service or purchase within the year available at time of inspection. Per FR, the fire extinguisher was recently serviced. LPA tested smoke and carbon monoxide detector to be in operable condition at time of inspection. LPA observed First Aid ki kept in Kitchent and was inventoried for necessary supplies. The FR has current Pediatric First Aid and CPR valid until 05/2025. Proof of immunization for pertussis and measles, and written declination for influenza vaccine was readily available during today’s inspection. The FR did not have proof of completion for required AB1207 Mandated Reporter Training available during today's inspection. Children's records were reviewed for completeness and required forms discussed. Record review was documented on LIC 857 which was provided during inspection.
Report Continues - Page 2 of 4

SUPERVISOR'S NAME: Denise Gibbs	TELEPHONE: (323) 558-2794
LICENSING EVALUATOR NAME: Katrina Chicote	TELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

Page: 2 of 10

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: TSINMAN & SUSTRETOVIENE FAMILY CHILD CARE	FACILITY NUMBER: 197414648
	VISIT DATE: 10/26/2023

NARRATIVE

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The following were discussed:
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

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.

NO Johnny jumpers, NO saucer chairs, NO incline sleepers and any other item that falls into that category are permitted in the facility.

LPA discussed the safe sleep regulations with FR and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed FR of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

AB 1207: Beginning on January 1, 2018, this law requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. Website: http://www.mandatedreporterca.com/

MyChildCarePlan.org – Centers and Family Child Care Homes Licensee [or facility representative] was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California. Megan’s Law - Family Child Care Homes
Report Continues - Page 3 of 4

SUPERVISOR'S NAME: Denise Gibbs	TELEPHONE: (323) 558-2794
LICENSING EVALUATOR NAME: Katrina Chicote	TELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

Page: 3 of 10

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: TSINMAN & SUSTRETOVIENE FAMILY CHILD CARE	FACILITY NUMBER: 197414648
	VISIT DATE: 10/26/2023

NARRATIVE

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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Based on this information, the following deficiencies on the attached LIC 809D are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

A notice of site visit was given and must remain posted for 30 days.

Exit interview was conducted and report was reviewed with the Facility Representative (FR), Anna Kuloyan.

Report Ends - Page 4 of 4

SUPERVISOR'S NAME: Denise Gibbs	TELEPHONE: (323) 558-2794
LICENSING EVALUATOR NAME: Katrina Chicote	TELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

Page: 4 of 10

Document Has Been Signed on 10/26/2023 04:33 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: TSINMAN & SUSTRETOVIENE FAMILY CHILD CARE	FACILITY NUMBER: 197414648
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(1)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and interview, Licensee did not meet above requirement. LPA observed fire extinguisher to not have service tag and proof of purchase was not available at time of inspection. This poses a potential health, safety, and personal rights risk to children in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	FR states she will discuss with Licensee and Licensee will photo of proof of service or receipt within the year by POC date via email.

Type B

Section Cited

CCR

102417(g)(9)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA record review and interview, Licensee did not meet above requirement. LPA did not observe LIC610A at time of inspection, LPA discussed with FR who was not able to provide for LPA to review at time of inspection. This poses a potential health, safety, and personal rights risk to children in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	FR states she will notify Licensee to fill out form (LPA provided) and provide copy to LPA by POC date via 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: Denise Gibbs	TELEPHONE: (323) 558-2794
LICENSING EVALUATOR NAME: Katrina Chicote	TELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

Page: 5 of 10

Document Has Been Signed on 10/26/2023 04:33 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: TSINMAN & SUSTRETOVIENE FAMILY CHILD CARE	FACILITY NUMBER: 197414648
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2023

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
1 2 3 4	Based on LPA record review and interview, Licensee did not meet above requirement. FR did not have proof of completion for AB1207 Mandated Reporter training at time of inspection. This poses a potential health, safety, and personal rights risk to children in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	FR states she will complete training and provide proof to LPA via email by POC date.

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: Denise Gibbs	TELEPHONE: (323) 558-2794
LICENSING EVALUATOR NAME: Katrina Chicote	TELEPHONE: 323-981-3350
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

Page: 6 of 10