313623112-5-16-2019-03-CC-TWAN-BC8THX-20190516144528

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313623112
Report Date: 05/16/2019
Date Signed: 05/16/2019 02:45:34 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:	BORYS, KATERYNA		FACILITY NUMBER:	313623112
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	05/16/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Kateryna Borys		TIME COMPLETED:	03:15 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 (LPA), Tanya Washington met with Applicant, Kateryna Borys for the purpose of an announced pre-licensing inspection. During today's inspection there were no children present in the home. Applicant stated that she plans to operate Monday-Friday from 7:00 AM to 6:00 PM. A health and safety inspection was conducted inside and out. This is a two story home with 4 bedrooms and 2 and half bathrooms, the downstairs floor has a dining room, family room, living room, half bathroom and garage. The second floor has all four bedrooms and two bathrooms. Off limit areas will consist of the garage and entire second floor. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. LPA observed a gate at the bottom of the stairs to prevent children from accessing the second floor. The applicant acknowledges that she must contact Licensing office prior to making an off-limits area on-limits and vice versa. The fireplace located in the living room is properly barricaded and will not be used during day-care hours. LPA observed cleaning compounds under the kitchen sink, applicant stated that she will install a latch and send a photo to LPA for correction. Functioning smoke and carbon monoxide detectors and a 2A10BC fire extinguisher were observed in the home. Applicant has completed the required Preventative Health and Safety course, she is enrolled to take the CPR and First aid class this upcoming Sunday, May 19th, 2019. Applicant stated there are no weapons in the home. The swimming pool has a five foot mesh fence with a self-latching and self-closing gate, there is also a hot tub located in the backyard, the hot tub is properly covered and latched on all four sides, applicant was reminded to keep the cover locked at all times while children are in care. Applicant was encouraged to maintain supervision at all times. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed. Report continues on 809-C.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2019

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

FACILITY NAME: BORYS, KATERYNA	FACILITY NUMBER: 313623112
	VISIT DATE: 05/16/2019

NARRATIVE

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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

This facility evaluation report was reviewed and discussed with the applicant. LIC 311D, records, postings, and reporting requirements were discussed. LPA discussed supervision, personal rights, criminal record clearances, staffing ratios and capacity, and maintaining buildings and grounds. Applicant was encouraged to visit the Department's website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes. LPA provided and discussed the Safe Sleep in Child Care brochure. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the applicant can request to be added to the distribution list to receive Quarterly Updates.

This home will be recommended for a Small Family Child Care license to serve a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6, pending the following items:

- photo of latched cabinets with cleaning compounds and knifes.
- second floor sketch (LIC999A) provided

License will be issued upon review by management.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2019

LIC809 (FAS) - (06/04)

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