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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494997
Report Date: 05/12/2022
Date Signed: 05/13/2022 05:11:26 PM


Document Has Been Signed on 05/13/2022 05:11 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:BUBENNOVA & PASECHNIKOVA FCCFACILITY NUMBER:
197494997
ADMINISTRATOR:ANZHELA BUBENNOVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 385-7058
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY:14CENSUS: 0DATE:
05/12/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:07 AM
MET WITH:Anzhela BubennovaTIME COMPLETED:
11:45 AM
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On 5/12/2022 at 8:07am, Licensing Program Analyst (LPA) Suzette Ornelas conducted an announced Pre-Licensing Inspection at 23300 Bassett Street West Hills Ca 91307. The purpose of the meeting was to ensure that health, safety and personal rights as required by Title 22 Regulations governing California Family Child Care homes will be met by the Applicant. This is an application for a Large Family Child Care Home, with an approved fire clearance dated 01/14/2022; 14 children-ages 18 months to 8 years of age. The family child care home will operate Monday thru Friday 8:00 a.m. to 8:00 p.m. LPA met with Applicant, Anzhela Bubennova, who guided LPA on a tour of the inside and outside of the home. LPAs observed 1 adults and 0 child in care.

Per facility sketch and tour of the home, the following was observed and discussed with the Applicant during the inspection:


Home is a 1-story dwelling with 3 bedrooms and 2 bathrooms. The first floor of the home consists of 1 living room, 1 living room/dining room area, 2 bedrooms, one bathroom, 1 master bedroom with 1 bathroom and a kitchen. The home has double latched gates on both sides of the home leading to the backyard. LPA observed the following:

· The living room is the first room upon entering the home, is on- limits and will be used for child care activities. Electrical outlets have safety covers installed. Small office desk is located at the corner of the room and no hazardous materials were observed.
· The living room/dining room area, is on- limits and will be used for child care activities and napping. Electrical outlets have safety covers installed. This room is equipped with one working dual carbon monoxide/smoke detector, as tested by the Applicant. Sliding door will be used when leading children to the backyard.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: BUBENNOVA & PASECHNIKOVA FCC
FACILITY NUMBER: 197494997
VISIT DATE: 05/12/2022
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-Bedroom one is on limits and will be used for child care activities. It is located on the left side of the hall way next to the on limits bathroom. There is a table, chairs and a television that is mounted and secured to the wall. There are shelf units against the walls that are safely secured to the wall. Scissors were observed at the top of the shelf unit and against the wall inaccessible to the children in care. There is a closet with a sliding door that contains additional art supplies and multiple glass cups. Applicant will be placing a latch on the sliding closet door to ensure that it is inaccessible to children in care.
-Bedroom two is on limits and will be used for child care activities. It is located on the far end right side of the hall way. This room is equipped with one working dual carbon monoxide/smoke detector, as tested by the Applicant. There is a closet with a sliding door that contains cots and children's toys. There are two other storage units that are secured to the wall containing children's toys as well as a table and chairs.
· The kitchen is off-limits and is made inaccessible from the living room/ dining room area by a baby gate making the kitchen inaccessible from the living room/dining room area. Kitchen cabinet and drawers containing hazardous materials and sharp objects are made inaccessible by safety latches.
· Bathroom one located in the hallway is on-limits to children in care.
· Front yard which is on limits when children enter the home. The front yard will not be used as a play area.
· Backyard is accessed through the living room/dining room area. An air conditioning unit is inaccessible to children in care by a sturdy barricade. Storage bin contents are inaccessible to children in care. Patio furniture/grill is inaccessible to children in care by a double latched wooden gate.

The following was also observed by LPAs during the inspection
1. All adults living in the home have submitted fingerprints and child abuse index check forms to Department of Justice.
2. Home is neat and clean.
3. There is no fireplace in the home, there are heating vents located in the living room and living room/dining room area that applicant will screen and make inaccessible to children in care.

4. Home is equipped with a fully charged fire extinguisher which is at least a 2A:10BC.

5. Home is equipped with at least 2 working smoke alarm/carbon monoxide detectors.


6. Home has a working telephone.
7. All poisons, detergents, cleaning compounds, medications, etc. are inaccessible to children or are locked.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: BUBENNOVA & PASECHNIKOVA FCC
FACILITY NUMBER: 197494997
VISIT DATE: 05/12/2022
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· 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. (AB) 633

· Applicant was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family child care home during the hours of operation.

· The fire extinguisher type 2A-10BC must be services annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries should be replaced.



· A current roster of children enrolled must be maintained and available. 1596.841

· Applicant was reminded to report any unusual incidents or injuries to the Child Care Regional Office by telephone within 24 hours and in writing within 7 days.

· Applicant was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome) and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome. Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials19-02 CCP Safe Sleep Awareness Campaign

· Applicant was reminded that only children eating may be in highchairs and that car seats are utilized only for transportation.


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

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: BUBENNOVA & PASECHNIKOVA FCC
FACILITY NUMBER: 197494997
VISIT DATE: 05/12/2022
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LPA discussed the safe sleep regulations with applicant 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 applicant, 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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



Exit interview conducted and report was reviewed with the applicant, Anzhela Bubennova. The home is in substantial compliance and ready for licensure.

LPA reviewed with applicant, Anzhela Bubennova. the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.



Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

A copy of this report was provided to the Applicant.

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

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6
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: BUBENNOVA & PASECHNIKOVA FCC
FACILITY NUMBER: 197494997
VISIT DATE: 05/12/2022
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8. Hazardous materials are inaccessible and kept out of the reach of children.
9. According to the Applicant, there are no weapons or firearms in the home. None were observed by the LPA.
10. Outdoor play area is free from defects or dangerous conditions.
11. Outdoor play area is fenced in.
12. No bodies of water were observed during the inspection.
13. Toys and play items are safe, clean, and appropriate for the ages of the children.
14. Applicant agrees that baby-walkers, bouncers, jumpers, and similar items will not be used for children in care and are kept inaccessible.
15. The home is equipped with a first-aid kit equipped with, cleansing pads healing ointment, bandages, gauze, and a digital thermometer.
16. Per applicant she will have a pet guinea pig caged at all times located in living room and will create a parent notification to provide parents upon registration.

The following was thoroughly discussed with the Applicant
· Applicant was made aware 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 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) 654-1541.
Email Address: childcareadvocatesprogram@dss.ca.gov

· Commencing September 1, 2016, SB 792, 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. LPA discussed the influenza waiver during the inspection.

· Beginning on January 1, 2018, AB 1207, 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. Website: www.mandatedreporterca.com. Licensee was reminded of their responsibility to report suspected child abuse.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: BUBENNOVA & PASECHNIKOVA FCC
FACILITY NUMBER: 197494997
VISIT DATE: 05/12/2022
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· Applicant was made aware that state law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category. 1596.846(b)(c)

· Applicant was reminded that it is the licensee’s, as well as anyone who assists in providing care, responsibility to know the regulations. Licensee was advised on how to access quarterly reports, forms, and regulations for Child Care online at www.ccld.ca.gov. Licensee was also encouraged to read the Child Care quarterly updates as they come out to stay informed of any changes or updates to statutes and regulations.



· 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.

· Due to the COVID-19 pandemic and local and state ordinances, licensee was directed to the CCLD.CA.GOV website for important updates and PINS. Licensee was directed to PIN 22-10-CCP.



Proof of corrections have been discussed with Applicant, including:

· Heater in the living room and living room/dining room area need to be covered/ barricaded and made inaccessible to children in care. Applicant will email LPA a correction picture.



· Applicant will install a knob cover for hot water knob in the on limits bathroom. Applicant will email LPA a picture.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (424) 301-3072
LICENSING EVALUATOR NAME: Suzette OrnelasTELEPHONE: 424-301-3008
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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