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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197417935
Report Date: 10/07/2022
Date Signed: 10/07/2022 10:45:50 AM


Document Has Been Signed on 10/07/2022 10:45 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:BULYOVSZKY FAMILY CHILD CAREFACILITY NUMBER:
197417935
ADMINISTRATOR:BULYOVSZKY, ELIZABETHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 917-6716
CITY:ENCINOSTATE: CAZIP CODE:
91316
CAPACITY:14CENSUS: 4DATE:
10/07/2022
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Elizabeth Bulyovsky, Licensee TIME COMPLETED:
10:55 AM
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On 10/07/2022 8:15am, Licensing Program Analyst (LPA), Denise Miranda conducted an announced Case Management – Licensee Initiated and was met by Licensee, BULYOVSZKY, ELIZABETH. Days and hours of operation are Monday through Friday 7am-6pm. Licensee requested to decrease her capacity from 14 children to capacity of 8 children.
The house is one story that includes: bedroom#1, bedroom#2, bathroom#1, living room combine with dining room, kitchen, and attached garage.
Licensee, guided LPA and toured the home inside and outside and a census was taken. LPA observed 4 children with Licensee.
Current facility sketch reviewed and Licensee confirmed that the living room combined with dining bathroom and bedroom #1, used for providing care and are accessible to children. Also, children have access to the bathroom#1.
The off-limits are: bedroom#2, kitchen is using only to access the backyard and detached garage. Licensee maintain a proof safety gate between kitchen and living room combine with dining room, in additional the garage is off-limit. Per Licensee the garage is use only for park her car and storage and no children has access. Licensee made inaccessible her bedroom#2 by use keys and maintain the door closed all times.
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.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
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: BULYOVSZKY FAMILY CHILD CARE
FACILITY NUMBER: 197417935
VISIT DATE: 10/07/2022
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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 (2-A:10-B:C). 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.

Present at the time of the inspection was Licensee. LPA verified that all adults present in the home have obtained criminal record clearances and are associated to the facility.

There are age appropriate toys and equipment for the children.

LPA reviewed the facility sketch (indoor and outdoor) and the floor plan does match with the physical plant of the home.

The Licensee has completed Mandated Reporter training on 07/17/2022. Prevention Health and Safety & Lead Poisoning Prevention Licensee enrolled to take the training on 10/17/2022. Licensee will submit the proof of completion to LPA Miranda via email no later 10/20/2022. Pediatric First Aid, Child/Infant CPR AED, Adult CPR renew on 06/07/2022 and will expire on 06/2024.

Licensee conducted a fire drill on 10/03/2022. Disaster drills shall be conducted at least every six months and Licensee is in compliance.


LPA review the emergency earthquake supplies, that licensee, will place all supplies together. Licensee will buy a portable radio, battery operated and food supplies.
Licensee agreed to place all earthquake supplies together inside of box/container/lugagge or anything will be easier for her to carry.

The following was discussed with the Licensee:
Individuals who are 18 years of age or older living in the home must obtain a
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
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: BULYOVSZKY FAMILY CHILD CARE
FACILITY NUMBER: 197417935
VISIT DATE: 10/07/2022
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criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

In the absence of the licensee 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 associated to the facility license.


-A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.
Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License shall be terminated.
-The fire extinguisher type 2A10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should check, and batteries replaced as needed.
-Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
-Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. (use LIC624 for written report).

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

The licensee was informed of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the

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

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
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: BULYOVSZKY FAMILY CHILD CARE
FACILITY NUMBER: 197417935
VISIT DATE: 10/07/2022
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public and parents on child care licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-154. Email Address: childcareadvocatesprogram@dss.ca.gov.

The following were also discussed with the licensee: Assembly Bill 633: Upon receipt by the licensee, licensees are to provide to parents/guardians the following: Copies of any licensing reports that document a Type A citation- this includes facility visits and substantiated complaint investigations; copy of licensing documents pertaining to a conference conducted by a local licensing agency management representative and the licensee of this family child care home in which issues of noncompliance are discussed or copies of a summary of an accusation indicating the Department's intent to revoke the facility's license. Copies of any of the above licensing documents the licensee has received in the prior 12 months shall be provided to parents/guardians of newly enrolled child at the facility.

Senate Bill 792: This bill, commencing September 1, 2016, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles.

New Appeal Process: A licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment. All appeals must be sent to: Department of Social Services | El Segundo Child Care Office | 300 N. Continental Blvd., Suite 290-A |El Segundo, CA 90245.

New Immunization Requirement: Law enacted by SB 277, beginning January 1, 2016, personal beliefs exemptions will no longer be an option for the vaccines that are currently required for entry into child care or school in California. Personal beliefs exemptions already on file will remain valid until the child reaches the next immunization checkpoint.

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

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
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: BULYOVSZKY FAMILY CHILD CARE
FACILITY NUMBER: 197417935
VISIT DATE: 10/07/2022
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Assembly Bill 1207: California Child Care Workers; Mandated Training Requirement. Beginning January 1, 2018, all licensed providers, applicants, directors and employees must complete Mandated Reported Training prior to March 30, 2018 and renew training every two years at: www.mandatedreporterca.com. 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 Miranda, provided the following forms: 311D Forms/Records to Keep in your Family in Child Care Home.


LPA also provided the following 1) booklet of Safe Sleep For your Baby SIDS. 2) Notification of Parents’ Rights, 3) Safe Sleep - Frequently Asked Questions, 4) Never ever shake a Baby by California Department of Social Services, 5) Prohibited Items in FCCH, 6) Drowning is silent flyer, 7) Capacity Regulation for Small Family Child Care Home - Flyer, 8) Safe Sleep Log - sample, 9)
Safe and Healthy Diapering in the Home, 10) Mandated Reporter Training , 11) and immunization card CDPH 286. 12) PIN - Best Practice Related to the Provision of Incidental Medical Services in Child Care Centers and Family Child Care Homes, 13) PUC 515 - Effects Lead Exposure.

The following is needed to be completed prior to Licensure:



* Licensee agreed to buy a portable radio/ battery operated and add extra batteries for her earthquake supplies. Juice 100%. Request by LIC9148 form.
* Licensee agreed to place all supplies and first aid together for her Earthquake Emergency.
* Declaration that Licensee obtained permission for temporary relocation.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
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: BULYOVSZKY FAMILY CHILD CARE
FACILITY NUMBER: 197417935
VISIT DATE: 10/07/2022
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Licensee will submit a proof of correction via email to LPA Miranda no later than 10/15/2022.
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: Denise MirandaTELEPHONE: (424) 301-3055
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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