313622026-9-12-2019-03-CC-TWAN-BFXRT3-20190912131740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313622026
Report Date: 09/12/2019
Date Signed: 09/12/2019 01:17:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME:	SARUMOVA, LYUBOV		FACILITY NUMBER:	313622026
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 7	DATE:	09/12/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Lyubov Sarumova		TIME COMPLETED:	01:40 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 (LPA) Tanya Washington met with Licensee, Lyubov Sarumova for the purpose of an unannounced annual/random inspection as well as capacity increase. Licensee requested to increase her capacity from 8 children to 14 children. Licensee has received the required fire clearance from Roseville Fire Prevention on 09/06/2019. LPA observed 7 children in care of Licensee and her husband Alexandr. All individuals subject to criminal background review have obtained a criminal record clearance. Facility operates Monday- Friday from 8:00 AM to 5:30 PM. A health and safety inspection was conducted in all areas accessible to children. This facility is a two story home with 4 bedrooms, 3 bathrooms, living room, dining room, unfenced front yard, fenced backyard and garage. Off-limits areas include entire second floor, laundry room, garage and the right side of backyard. Main area for care is the living room and the dining room. There is a downstairs bedroom utilized for napping purposes. LPA observed a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. There are no accessible bodies of water on the premises. Toxic and hazardous items are inaccessible to children. Safe toys and comfortable accommodations were observed. LPA reviewed files for the children who were present today and observed required Consent for Medical Treatment LIC627 and signed Parents Rights LIC995A. Current pediatric CPR and first aid certification was verified for Licensee. LPA observed that the last fire drill was conducted on 05/28/2019. LPA discussed the requirement of maintaining a children's roster on LIC9040 form. Proof of required vaccines for Licensee have been verified. Licensee has completed the required Mandated Reporter Training on 03/10/18. LPA verified that the annual Licensing fees are current. Continues on LIC809C

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2019

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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: SARUMOVA, LYUBOV	FACILITY NUMBER: 313622026
	VISIT DATE: 09/12/2019

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
26
27
28
29
30
31
32

This provider is currently not providing IMS services to children in care. 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 the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so Licensee can request to be added to the distribution list to receive Quarterly Updates. LPA provided and discussed the Safe Sleep in Child Care and Effects of Lead Exposure brochures.

Capacity increase is approved for a Large Family Child Care Home as of today, September 12, 2019. Facility is now licensed to serve a maximum capacity (when there is an assistant present) of 12 children with no more than four infants OR a capacity of 14 children no more than three Infants; one child must be in Transitional Kindergarten/Elementary School and one child must be at least six years old. If there is not an assistant present, the facility must revert to a Small Family Child Care Home license requirements.

This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this report.

No Title 22 deficiencies are observed during today's inspection.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2019

LIC809 (FAS) - (06/04)

Page: 2 of 2