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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417935
Report Date: 07/05/2022
Date Signed: 07/05/2022 03:48:30 PM


Document Has Been Signed on 07/05/2022 03:48 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:BULYOVSZKY FAMILY CHILD CAREFACILITY NUMBER:
197417935
ADMINISTRATOR:BULYOVSZKY, ELIZABETHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 917-6716
CITY:ENCINOSTATE: CAZIP CODE:
91316
CAPACITY:14CENSUS: 4DATE:
07/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:BULYOVSZKY, ELIZABETH- LicenseeTIME COMPLETED:
04:00 PM
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On 07/05/2022 Licensing Program Analyst (LPA), Suzette Ornelas conducted an unannounced Annual Required Inspection and was met by Licensee, BULYOVSZKY, ELIZABETH. Days and hours of operation are Monday through Friday 7a to 6p.

LPA toured the home inside and outside and a census was taken. LPA observed 4 children. Current facility sketch reviewed and Licensee confirmed that the living room, bathroom and bedroom 1 are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of closed doors, supervision and child proof gates. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.

There are no fireplaces or open face heaters in the home. There is a working fire extinguisher located in between the living room and kitchen area that was purchased on 01/2022. LPA observed working smoke detector and carbon monoxide detector located in bedroom 1 as well as the living room. Adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (818) 917-6716.

There is currently one infant in care. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2022
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: BULYOVSZKY FAMILY CHILD CARE
FACILITY NUMBER: 197417935
VISIT DATE: 07/05/2022
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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. Licensee was reminded to ensure that the equipment is dusted as needed. Capacity as specified on the license is being maintained. LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training has not been completed. LPA provided licensee with website information. Licensee will submit proof of completion to LPA via email. Licensee is aware the training is to be completed every two years. Licensee’s pediatric CPR/First Aid expires on 06/2024. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza and pertussis; however, LPA did not observe Licensee immunization records for MMR. Licensee will submit proof via email to LPA.

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.

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, 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.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
LIC809 (FAS) - (06/04)
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