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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417528
Report Date: 08/11/2022
Date Signed: 08/11/2022 10:57:57 AM


Document Has Been Signed on 08/11/2022 10:57 AM - 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:KUTSEVOL FAMILY CHILD CAREFACILITY NUMBER:
197417528
ADMINISTRATOR:KUTSEVOL, ALINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
3236104645
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91423
CAPACITY:14CENSUS: 7DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Alina Kutsevol, Licensee and Anna Smart, Co-Licensee TIME COMPLETED:
11:15 AM
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On 8/11/2022 at 8:10am Licensing Program Analyst (LPA), Denise Miranda conducted an unannounced Annual Required -1 year Inspection and was met by Licensee, Alina Kutsevol. Also, was present Anna Smart, Co-Licensee and 4 children (no infants). Per Licensee, the hours of operation is from Monday – Friday - 8AM- 6PM. Upon arrival LPA provided a copy of Entrance Checklist - Family Child Care to Licensee.
During this inspection, Licensee provided a copy of the certification of occupancy of the converted of portion detached garage to recreation room with half bathroom that was granted on 2/12/2014. LPA inspected this area, per licensee, this area is on limit. A new Sketch form LIC999A (floor plan and yard) will be submit by Licensee and Co-Licensee no later than 08/19/2022. Licensee agreed to mail the original form to LPA Miranda.
The following areas are designated as follows and Licensee confirmed the: Living room, dining room, den/playroom room, Bathroom#1 and converted detached garage to recreation room with a half bathroom#2, backyard, den were accessible to the children in care.

The off-limit: Off limit area the bedroom#1, bathroom#1, carpool garage, kitchen and laundry room.


There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No pets. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

LPA observed no fireplace. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. Safe toys and play equipment are observed. Furniture was observed with no loose or sharp parts, clean and in good repair.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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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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: KUTSEVOL FAMILY CHILD CARE
FACILITY NUMBER: 197417528
VISIT DATE: 08/11/2022
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At 10:15:00am LPA observed 3 more children arriving at the facility. At total 7 children in care and no infant.

The home has working telephone service and LPA confirmed the phone number is (323) 610-4645.

LPA discussed Safe Sleep Regulations with licensee.

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats were not observed at facility. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained.

LPA reviewed all children’s files and observed all files were completed. Licensee’s and Co-Licensee’s Mandated Reporter Training was completed on 7/26/2022, Mandated Reporter training is due for renewal on 7/26/24. Licensee’s pediatric CPR/First Aid completed on 07/27/2022 and is due for renewal on 07/27/2024. There no currently employees at the facility present at this time. Per Licensee, she has one employee.

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 and Co-Licensee are 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.



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.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
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: KUTSEVOL FAMILY CHILD CARE
FACILITY NUMBER: 197417528
VISIT DATE: 08/11/2022
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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.

Licensee and co-Licensee were 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.

LPA discussed the safe sleep regulations with licensee 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 licensee 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.

Staff interview conducted and documented at 9:42am.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.

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.

Exit interview conducted and report was reviewed with the Licensee. Report, and Notice of Site Visit was given to Licensee, Alina Kutsevol.

SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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