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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313601
Report Date: 05/15/2019
Date Signed: 05/15/2019 10:03:52 AM

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:SHATERNIK, OKSANAFACILITY NUMBER:
304313601
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
05/15/2019
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Applicant and her adult sonTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Mahnaz (Nancy) Malek conducted an announced Pre-licensing inspection of this home. Present in the house was the applicant, Oksana Shaternik and her adult son, Vladyslav Shaternik. The applicant's adult son translated from English to Russian language for her parent. LPA toured the home with the applicant and her adult's son. Applicant states that she plans to take care of children from 2 to 6 years old, Monday through Friday from 8:00am - 6:00 pm.
Currently there are two other adults besides the applicant and two minor children live in the house. Review of adults' records on today's date indicates that all adults live in the house or individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.
This is a two story single home. One room has been designated for children's use. Children's bathroom is located downstairs and is for children's use. Children will eat in the kitchen. The kitchen's cabinets and drawers are either equipped with safety locks or have no hazardous items. The living room and dinning room are the areas children pass to go to bathroom or back yard. The children's area has age appropriate toys and equipment for children. The garage and laundry room are equipped with locks. The applicant was advised children cannot use the garage. There is a gate installed in front the stairs. Upstairs area are off limits. There are four bedrooms, and two bathrooms upstairs which are off limits.
According to applicant, there is no gun in the house. The fire extinguisher meets regulations (2-A-10-B:C). There is no body of water in the house. Smoke detector and Carbon Monoxide are in working condition. The back yard was inspected. It is all fenced. There is no high play structure equipment observed. The applicant has fenced off the rose bushes. There was a sand box which was covered in the back yard. Two rabbits in the back yard observed behind a fence.
Incidental Medical Services (IMS) policy was discussed
For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care
Continued on page 2
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 703-2810
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2019
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 2
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: SHATERNIK, OKSANA
FACILITY NUMBER: 304313601
VISIT DATE: 05/15/2019
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Homes Sections 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.htmThe Notice of Site Visit was posted. Facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. The licensee was informed that they can refer to our Department website at www.ccld.ca.gov for obtaining the quarterly updates.
Appeal Rights were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days. First level appeal is to Regional Manager, address is above on the report. The required forms were discussed with the licensee at this inspection. The children's forms, facility forms, fingerprinting forms, posting, roster, unusual incident form, and fire drill log were all reviewed and discussed. The licensee was also informed that the LIC 508 must be submitted with all Criminal Background Clearance Transfer Request (LIC 9182) and a picture ID for all the associations http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htmhttp://cchp.ucsf.edu/content/disaster-preparedness. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org

A copy of child care provider's guide to safe sleep pamphlet was given to the applicant.
A copy of Never Ever Shake a Baby pamphlet with the website www.dontshake.org was given to the applicant. An updated pamphlet regarding safe sleep regulations in childcare and a pamphlet for lead poisoning facts were given to the applicant today.

A small family child care home license is issued today.
Exit interview was conducted with the applicant and her adult son translated in Russian language for the applicant.

This report ends here.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Mahnaz MalekTELEPHONE: (714) 703-2810
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2