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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304204618
Report Date: 08/02/2019
Date Signed: 08/02/2019 09:56:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:FOMENKO, CYNTHIAFACILITY NUMBER:
304204618
ADMINISTRATOR:FOMENKO, CYNTHIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 865-5438
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:14CENSUS: 10DATE:
08/02/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lory Tescum, AssistantTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yesenia Villa conducted an unannounced annual random site inspection to ensure the health & safety standards as required by regulations governing family child care homes. Upon arrival, LPA met with Lory Tescum, assistant as the Licensee was not present. Per Licensees phone conversation with LPA she was out of town out of state for the weekend and left her two assistants in charge. Also present during todays inspection was Elizabeth Nicholson, assistant. LPA toured the facility inside and outdoors. There were 10 children present in the home, (2) of which were infants. The facility was observed to be within ratio during todays visit. Licensees operating hours are Monday thru Friday from 7am to 5:30pm.Per Licensee there are 4 adults residing in the home. All adults residing in the home are fingerprint cleared. Per Licensee she has 14 children enrolled in the day care. An updated roster was not available during the inspection, she had 20 children listed in her roster and stated that the roster needed to be updated.

This is a two story home with 5 bedrooms and 4 bathrooms.The following areas used for day care: are the living room, the playroom located in the back of the home and the bathroom located downstairs in the hallway. Licensee states the off-limit areas are the five bedrooms, kitchen, front room and the back yard.

The licensee enclosed the off limit areas by locking all doors making it inaccessible for the children to reach the off-limit areas. The stairs to the second floor are closed off, inaccessible by an iron gate.

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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2019
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618
VISIT DATE: 08/02/2019
NARRATIVE
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The children use the front yard for outdoor play time. There were no hazards observed in the outdoor areas during today’s inspection. The front yard is not fenced, assistant was reminded that full supervision is required at all times when children are out to play. The yard was observed to have appropriate toys for the children. There are no firearms in the home as per licensees assistant.

Licensee has the Parent’s Rights poster and other appropriate forms posted on wall in her living room in a clip board. Pediatric First Aid/CPR certificate for assistant is valid thru 03/12/2020. Licensees disaster drill log notes indicated last drill was conducted on 07/05/2019.

Licensee has a working telephone via cell phone. The licensee's assistant has completed the mandated reporter training on 12/12/17 and her assistant completed the mandated reporter training on the same date of 12/12/17. Assistant has been advised that this training must be renewed every two years. Immunization's required, MMR, TDAP and the Influenza shot were not verified for both assistants. Adult#1 had proof of immunization's, Adult#2 and licensee did not have proof of immunization's during this inspection. Ten children’s files were reviewed for LIC700 and Blue Immunization card. Files were not complete as Licensee did not have Child#10.'s file accessible during the inspection. Per assistant after looking for child's file, stated the file was locked in the licensees bedroom and is inaccessible. Detergents and cleaning supplies were inaccessible to the children in care. Fire extinguisher was inspected and met state regulations. There is an operational smoke detector and carbon monoxide in the back play room. The licensee maintains a First Aid Kit in the home. There are adequate age appropriate toys, books, and games. The following were discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to being in the presence of the children in care. Individuals within one month of their 18th birthday must be fingerprinted immediately. No smoking, No infant walkers, No baby bouncers, No Johnny jumpers, No exersaucers and any other item that falls into that category. LPA discussed disaster drills, posting requirements, children records requirements, mandated child abuse and injury/death reporting. Page 2 of 3

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2019
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618
VISIT DATE: 08/02/2019
NARRATIVE
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LPA reviewed SIDs, Never Shake A Baby, safe sleeping practices pamphlet. Infants should sleep mouth up, on their backs, free of clutter surrounding their sleeping space. Safe sleep guidelines flyer was provided during todays visit.

Incidental Medical Services (IMS) policy was discussed. Licensee states there are no children requiring medication. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

LPA advised the Licensee to access forms and quarterly updates with recent changes to regulations on line at: www.ccld.ca.gov.


The following deficiencies were cited on the 809D page.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 consecutive days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00. Exit interview was conducted with Licensee and Appeal rights were provided and explained. Licensee was informed that appeals must be submitted in writing within 15 days of a citation.

An exit interview was completed with Lory Tescum, Assistant. Page 3 of 3
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2019
LIC809 (FAS) - (06/04)
Page: 3 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2019
Section Cited
HSC
1597.622
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Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Licensee states she will submit proof of immunizations for adult#2. assistant by POC date of 08/09/19.
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Proof of immunization against pertussis, measles, flu shot or waiver were not available for review during today's inspection for the licensees assistant Adult#2 assistant. This poses a potential health and safety risk to the children.
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Type B
08/09/2019
Section Cited
CCR
102417(g)(8)
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102417(g)(8) Operation of a family child care home. Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement was not met as evidence by the childrens roster was not up to date on this visit.
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Licensee states she will submit proof of updated childrens roster by POC date of 08/09/19.
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This poses a potential risk to the health and safety to the children in care.
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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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2019
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2019
Section Cited
CCR
102421(a)(b)
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Child's Records, 102421(a)(b)
The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).The licensee shall maintain, in each child's record, a copy of the emergency information card required in Section 102417(g)(7).
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Licensee states she will submit proof of Licensing forms and immunizations to the Department by POC date of 08/09/19 for child#10.
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This requirement was not met as evidence Licensee did not have records for child#10. This poses a potential risk to the health and safety to the children in care.
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Type B
08/09/2019
Section Cited
HSC
1596.8662(2)(b)
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1596.8662(2)(b) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal
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Licensee states she will submit proof of Mandated Reporter training by POC date of 08/09/19 for Adult#2.assitant.
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mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement was not met as evidence by Adult#2. did not have mandated reporter training certificate. This poses a potential risk to the health and safety of the children in care.
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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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5