<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419511
Report Date: 06/23/2022
Date Signed: 06/23/2022 11:51:56 AM


Document Has Been Signed on 06/23/2022 11:51 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:MOSKALENKO FAMILY CHILD CAREFACILITY NUMBER:
197419511
ADMINISTRATOR:ANASTASIA MOSKALENKOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 448-3952
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:14CENSUS: 9DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Anastasia Moskalenko - LicenseeTIME COMPLETED:
12:00 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 06/23/2022 Licensing Program Analyst (LPA), Suzette Ornelas conducted an unannounced Annual Required Inspection and was met by Licensee, Anastasia Moskalenko. Also present were Staff #1 (S1), Staff #2 (S2) and Licensees Step Mother (S3). Days and hours of operation are Monday through Friday 8a to 6p.

This is a single story dwelling located in the back of the main home. The dwelling has 2 bedrooms, 1 bathroom, living room, kitchen, outdoor patio and backyard. The dwelling has its own address. The entrance of the applicant's home has a 5 ft. wooden fence on one side and a 5 ft, white, iron fence on the other side which completely separates the applicant's home from the front home. There is a swimming pool in the backyard of the main front home. There is a 5 ft, white, iron fence and a cement wall which separates the applicant's stepmother's backyard from the applicant's front yard making the swimming pool area inaccessible to children. No furniture or items were positioned next to the fence that would render the pool fence to be climbable. The fence allows visibility of the pool.

Main care will be provided in the living room. Children will eat in the living room. Children will nap in the applicant's bedroom. Napping equipment was observed. LPA observed safety latches on all kitchen and bathroom cabinets. Medications are stored in an upper kitchen cabinet near the living room.
LPA toured the home inside and outside and a census was taken. LPA observed 9 children in the facility. Current facility sketch reviewed and Licensee confirmed that the bathroom, living room and bedroom are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of closed doors, locked doors and supervision.

There are no firearms or ammunition on the premises. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.
There are no fireplaces or open face heaters in the home.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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 5


Document Has Been Signed on 06/23/2022 11:51 AM - 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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245


FACILITY NAME: MOSKALENKO FAMILY CHILD CARE
FACILITY NUMBER: 197419511

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above in 1 out of 9 total children did not have immunization records on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2022
Plan of Correction
1
2
3
4
Licensee contacated parent to obtainn child records and will submit proof of childs immunization records via 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 RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


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: MOSKALENKO FAMILY CHILD CARE
FACILITY NUMBER: 197419511
VISIT DATE: 06/23/2022
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
26
27
28
29
30
31
32
 There is a working fire extinguisher located in the living room, smoke detector, carbon monoxide detector located in the living room area as well as the large bedroom and 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 (310) 448-3952.
There are currently no infants in care. 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 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. 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; however, Immunization records for 1 child were not readily available. LPA informed licensee to ensure all children’s immunization records are provided upon admission and provided licensee with the immunization regulation. Licensee will submit proof of child immunization record via email. Licensee’s Mandated Reporter Training was completed in 2022. Licensee’s pediatric CPR/First Aid expires in 2024. All staff present had FIrst Aid and CPR training as well as Mandated Reporter Certificated that were current. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles. 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.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: MOSKALENKO FAMILY CHILD CARE
FACILITY NUMBER: 197419511
VISIT DATE: 06/23/2022
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
26
27
28
29
30
31
32
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: Type B: 102418(g) – Immunization's: Children Records (see next page, 809 D) Licensee was provided a copy of appeal rights.

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: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5