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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313419
Report Date: 03/03/2020
Date Signed: 03/03/2020 02:17:31 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:PRISYAZHNYUK, YULIAFACILITY NUMBER:
304313419
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
03/03/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Yulia PrisyazhnyukTIME COMPLETED:
02:45 PM
NARRATIVE
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An Annual inspection was conducted at the facility by Licensing Program Analyst (LPA) Dean Valencia. LPA observed licensee an an adult assistant caring for 4 children; of which 4 are infants (birth through and up to 2 years old). Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date indicates all individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 2 adults residing in the home.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of baby gates. There is at least one working carbon monoxide, smoke detector, and fire extinguisher 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. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspection. There is no fireplace in the home. The home has age appropriate toys and they are in good repair. The children use the backyard as an outdoor play area. The play area appeared safe and no hazards were observed. The play area was observed to be fully fenced and play equipment is age appropriate and in good repair. There are no bodies of water on the premises. The licensee has a current roster of children in care. Records of children present during LPA’s inspection were reviewed, and some documentation was not available at the time of the inspection. The licensee has current Pediatric CPR/First Aid certification, expiring 1/16/2022. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, 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. Proof of immunization against pertussis, measles for employees/volunteers were reviewed and within compliance. 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. (Continued on LIC809C, Page 2)
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2020
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 3
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: PRISYAZHNYUK, YULIA
FACILITY NUMBER: 304313419
VISIT DATE: 03/03/2020
NARRATIVE
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(Page 2) 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 Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

The licensee understands children are never to be left in parked vehicles and if licensee is temporarily absent from the facility, arrangements must be made for an assistant to supervise children. The substitute assistant must have the required criminal record, child abuse index clearances, immunization's, Pediatric CPR/First Aid, and mandated reporter training.



CCLD website www.ccld.ca.gov 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. A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.
End of Report.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: PRISYAZHNYUK, YULIA
FACILITY NUMBER: 304313419
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2020
Section Cited

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Parent's Rights: A ...any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b. H&S 1596.8595

Based on a review of the children's records
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it was observed that 4 of the 4 records reviewed did not meet the above H&S code. This was observed during a review of the children's records, by LPA. This poses a potential threat to the children's health and safety.
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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: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3