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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304204618
Report Date: 02/20/2025
Date Signed: 02/20/2025 12:08:21 PM

Document Has Been Signed on 02/20/2025 12:08 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:FOMENKO, CYNTHIAFACILITY NUMBER:
304204618
ADMINISTRATOR/
DIRECTOR:		FOMENKO, CYNTHIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 865-5438
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
02/20/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Fomenko, Cynthia (Licensee)TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 2/20/2025, an unannounced inspection was conducted at the facility by Licensing Program Analyst (LPA) Vivian Trinh. At 9:00 AM observed licensee and assistant Fomenko, Robert, caring for total 7 chidlren, which included 2 infants, 5 preschool were playing in the Living Room. The licensee was operating within the licensed capacity as specified on license.

A review of the Facility Personnel Report Summary on this date 2/20/25 indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are two (2) adults including the licensee and Zero (0) minor child living in the facility. Facility Day care hours are 7:30 am-5:30pm, Monday through Friday.

During today’s inspection, the LPA and licensee toured the inside and outside areas of the facility, sketch LIC 999 as accessible to childcare children. This is a two story home with 3 bedrooms and 3 1/2 bathrooms. License has placed a safety gate at the bottom of the stairs leading to the 2nd floor, ensuring it is inaccessible to children in care. Off-limits areas are made inaccessible by means of baby gates, and latches.
Licensee stated that OFF LIMITS areas include: all bedrooms upstairs, 1 room on the end left hallway, garage, backyard, front yard, and Storages. The licensee acknowledged that children may never enter these off-limit areas.

INDOOR INSPECTION: The childcare area consists of the family room, the playroom located in the back of the home, and the bathroom located downstairs in the hallway. During today's inspection, each child was observed to have safe, healthful, and comfortable accommodations, furnishings, and equipment.

ON-SITE FOOD PREPARATION: The facility provides breakfast, lunch, and snacks to the children. At the time of inspection, food prep areas were clean and sanitary, and food was properly stored. Filtered drinking water is available to children in care. The LPA observed that the facility’s floors, equipment, furniture, and clients’ bathrooms were clean and in good repair. Continued Page 2.
Nguyen K TranTELEPHONE: (714) 658-6048
Vivian TrinhTELEPHONE: (949) 466-1624
DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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Document Has Been Signed on 02/20/2025 12:08 PM - 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868


FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on, observation, interview, record review. the licensee did not comply with the section cited above. At 9:00 AM during document reviews, and interviewed Staff #2 does not have current immunization record (immunization record) MMR, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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The licensee stated will submit to LPA for staff #2 the proof of immunization records before the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Nguyen K TranTELEPHONE: (714) 658-6048
Vivian TrinhTELEPHONE: (949) 466-1624

DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618
VISIT DATE: 02/20/2025
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OUTDOOR INSPECTION: Licensee stated they do not use the backyard and front yard for outdoor play. There are no bodies of water, and pets on the premises.

Garage will not be used for day-care. The applicant stated the garage will be off-limit.

Garage is to be utilized for limited activities, day-care children are not to napped or eat in the Garage.

There are working carbon monoxide, smoke detectors, that should be type 2A-10BC, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. There were no poisons or other items observed which could pose a danger to children or if they were observed, they were locked or inaccessible. Licensee stated there are no firearms or other dangerous weapons in the facility and none were observed during today's inspections. There is a no fireplace. The home has age-appropriate toys for the ages served. The Licensee is aware that each FCCH shall conduct fire drills and disaster drills at least once every six months. A record review shows that the last drill was documented on 2/11/25. LPA verified there is a working telephone service (cellular service), licensee was reminded that childcare phone needs to remain the in the childcare at all times. Licensee stated they use the backyard for outdoor play.

The licensee does have a current roster of children in care of 7 children records for children present during the LPA inspection time. Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A) and found to be in compliance. Licensee stated, there is 2 infants under 24 months enrolled in the childcare. LPA reviewed LIC 9227 Individual Infant Sleeping Plan and napping log for infants.

Continued Page 3.
SUPERVISOR'S NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR NAME: Vivian TrinhTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618
VISIT DATE: 02/20/2025
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The licensee and assistant’s Pediatric CPR/First Aid certification expired 5/2026. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee was reviewed and within compliance. At 9:00 am, during staff file review and interview, staff #2 (S2) did not have proof of immunization against , (MMR).

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training and to renew the training every two years. During staff file review licensee’s mandated reporter certificate expired 7/2025.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/

The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

CCLD website www.cdss.ca.gov/inforesources/community-care-licensing was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee. Continued Page 4.
SUPERVISOR'S NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR NAME: Vivian TrinhTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618
VISIT DATE: 02/20/2025
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LPA discussed the safe sleep regulations with licensee Fomenko, Cynthia 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 licensee [facility representative] 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.

Licensee Fomenko, Cynthia was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed and cited at the time of the visit. Administration of Child Day Care Licensing HSC 1597.622(c) (see LIC 809D).

Licensee Fomenko, Cynthia was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Continued Page 5.
SUPERVISOR'S NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR NAME: Vivian TrinhTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: FOMENKO, CYNTHIA
FACILITY NUMBER: 304204618
VISIT DATE: 02/20/2025
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Exit interview conducted and report was reviewed with the licensee Fomenko, Cynthia. A notice of site visit was given and must remain posted for 30 days.

During the exit interview, the licensee, Fomenko, Cynthia , confirmed that there are no Registered Sex
Offenders living in the facility and LPA completed the RSO profile in FAS.

End of Report.
SUPERVISOR'S NAME: Nguyen K TranTELEPHONE: (714) 658-6048
LICENSING EVALUATOR NAME: Vivian TrinhTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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