304313786-9-23-2021-06-CC-KDEI-C75R8T-20210923124829

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313786
Report Date: 09/23/2021
Date Signed: 09/23/2021 12:48:50 PM

Document Has Been Signed on 09/23/2021 12:48 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	ZOLOTUKHINA, KRISTINA		FACILITY NUMBER:	304313786
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 7	DATE:	09/23/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Licensee Ms. Zolotukhina, Kristina		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst’s (LPA’s) Ketki Desai conducted an unannounced In-person Case Management. License initiated inspection for a change in capacity at the existing Family Child Care home. LPA met with Licensee's Ms. Zolotukhina, Kristina present at the site, providing care and supervision to 7 children, along with one assistant. The children were in the age group of 3-6 years old. A review of the Facility Personnel Report Summary indicates all adults, residing in the home & assistant who require caregiver background check clearances are cleared. Licensee is requesting a Large family childcare home license. Per Licensee, operation hours will be Monday to Friday, 8.00 AM to 6.00 PM. Licensee states that she will care for children 2.5 years to 6 years only. Preschool age only All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a two-story home with 4 bedrooms, 3 bathrooms, living room, dining room, kitchen, family room, and backyard that is fenced. Licensee has placed the second story as off limits and has placed child proof gates and door handles to prevent the children from entering the off-limit areas during operation hours. The licensee acknowledged the children may never enter the off-limit areas. Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating. The home has a central Air /Heating system. The A/C unit is in the area inaccessible to children (Backyard surrounded by a safe wooden fence barrier) Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The licensee states (that there are no poisons on the premises). Licensee was advised that any poisons must be locked with a key or combination lock (1)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ZOLOTUKHINA, KRISTINA	FACILITY NUMBER: 304313786
	VISIT DATE: 09/23/2021

NARRATIVE

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Licensee stated she is not currently registered with any Foster Care agency or holds a foster parent license, she was informed if any changes are to occur, Department shall be notified.

Based on the Facility Sketch submitted, areas off limits to children and parents are: Entire second level , garage, living area , dining and kitchen on the first level of the home as Off - limits area. Since the children use a separate entrance gate located on the side end of the home, leading into the Day Care area, the entire other side of the first level is inaccessible to children. Licensee understands that licensing staff may have access to off-limit areas during inspection visit if necessary.
LPA also observed COVID19, precautions at the facility, with required postings, temperature checks upon arrival, social distancing and activities being held in small groups.

Areas Designated for Day care activities: Licensee has designated the family room, one bathroom, and backyard as part of her day-care.

Children shall enter the home through the side entrance, of the home, they walk into the designated back yard area and the Day care room . These area is used mainly for all activities. It was observed to have age appropriate toys along with Arts and Crafts activities. There is a fire place in the day care area, which is completely covered with a wooden book shelf serving as a safe barrier

The bathroom designated for day care use was observed to be safe and free of hazardous items. Bathroom was clean. It is located at the end of the day care room, next to the garage door which was also locked with child safety knobs and a duel lock.

OUTDOOR PLAY AREA: Backyard is designated for outdoor play area, it is fenced and has concrete and grassy area, it has age appropriate outdoor toys. Shade is provided by Awing and age appropriate climbing structures are placed on the grass area. There is a gardening activity spot for the children .

There are no firearms, weapons or bodies of water on the premises.

Licensee states that she provides Breakfast/ Lunch and snacks for children in care. Food brought from the children’s homes, those containers shall be labeled with child’s name and properly stored or refrigerated. (Page-2)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ZOLOTUKHINA, KRISTINA	FACILITY NUMBER: 304313786
	VISIT DATE: 09/23/2021

NARRATIVE

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Licensee along with the assistants have completed the required Pediatric First Aid and CPR which expires 2/13/2023 There are first aid supplies available.

Licensee has a cell phone and an additional cell phone which is used for childcare. The additional cell phone remains on the premises during hours of operation.

The following was discussed with the applicant: ·Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately.

Civil Penalties will be assessed if not in compliance.
·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 Pediatric First Aid and CPR certification and a valid criminal record clearance associated to the facility license.

·Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.

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

Applicant was also made aware of the Child Advocacy program so she could receive the updated Quarterly reports and other information in a timely manner. ChildCareAdvocatesProgram@dss.ca.gov

Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

Fire and safety drills must be performed every six months and documented for review by the Department.
Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ZOLOTUKHINA, KRISTINA	FACILITY NUMBER: 304313786
	VISIT DATE: 09/23/2021

NARRATIVE

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Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
No smoking, no infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

Incidental Medical Services (IMS): policy was discussed. 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 provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)

Capacity Handout for a Small Family Child Care Home and Large Family Child Care Home was provided.

Fire inspection from Orange County Fire Authority Fire inspection services have granted the fire clearance on 9/13/21

The licensee does have a current roster of children in care. Three children files and two staff files were reviewed on today's inspection and meets the requirements.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ZOLOTUKHINA, KRISTINA	FACILITY NUMBER: 304313786
	VISIT DATE: 09/23/2021

NARRATIVE

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The licensee does have a current roster of children in care. One file was reviewed and meets the requirements.

Fire drills have been conducted by the Licensee in the past quarter.

The facility was complying with Title 22 Regulations for Family Child Care, at the time of inspection.

A license for a Large Family Child care home shall be issued after final review, in the event additional requirements are needed, the Licensee will be notified.

On today’s inspection each child was observed to have a safe, healthful and comfortable accommodation furnishing and equipment’s.

An exit interview conducted with licensee. 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.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021

LIC809 (FAS) - (06/04)

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