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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313623112
Report Date: 08/28/2020
Date Signed: 08/28/2020 11:13:13 AM

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, KATERYNAFACILITY NUMBER:
313623112
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
08/28/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kateryna Borys - LicenseeTIME COMPLETED:
11:00 AM
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Licensing Program Analysts (LPA) Katrina Owens is conducting a Case Management tele-inspection with licensee Kateryna Borys for the purpose of a capacity increase from 8 to 14 children. The inspection is being conducted via Face-Time due to Covid-19 pandemic.

A virtual tour of the home inside and out was conducted by LPA Owens. 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. LPA explained about obtaining $300,000 liability insurance. She understands that until a policy is obtained, she must use the affidavit.

Applicant has certificates of completion for 15 hours of health and safety training including CPR and First Aid with expiration date of 5/2021. All adult residents received criminal record clearances. LPA reminded applicant of the applicable Civil Penalty per person for those adults including your own child who have not received fingerprint clearances, are not associated to the license, come in contact with and or provide care and supervision to the children. LPA has provided the Applicant with the web site to enable access to all updated forms, requirements and changes. Applicant understands that she needs to notify licensing for any modification inside and out of the home. There is a shed in the backyard that is behind a fence making the fence inaccessible to day care children.

Off-limit areas include the entire upstairs, all bedrooms and garage. Applicant understands that children may never enter these off-limit areas. LPA reviewed the fire drill requirements. The fire place contains a screen. Applicant stated there are no weapons in the home. Fire extinguisher, carbon monoxide detector and smoke detectors meet regulation. Hazardous cleaning compounds are inaccessible to children. Sharp utensils and Medications are inaccessible to children.

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SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Katrina OwensTELEPHONE: 916-263-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2020
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: 08/28/2020
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The backyard is fenced Applicant understands that 100% supervision is required in any unfenced areas. There is pool on the premises and the fencing around the pool meets Title 22, Division 12, Chapter 3 Regulations with a self closing, self latching gate that swings away from the pool . There is also a spa that has a locked top. Applicant will supervise day care children at all times. There are no pets at the home. Stairs are barricaded when children under age 5 years old are present. Planned hours of operation are Monday through Friday, 7 am to 6 pm and other hours as arranged.

LPA Owens discussed SB 277 (public health vaccination) and SB 792 (day care facilities: Immunization exemptions) with licensee at time of tele-visit. LPA observed proof that licensee and staff/ volunteers have met the requirements of SB 792. LPA observed that all staff has completed the required mandated reporter training (AB 1207) at website: www.mandatedreporterca.com.

This facility is not providing Incidental Medical Services-IMS at this time. LPA discussed IMS services and the requirement to create a plan of operation. Specifics on the plan can be found in the family child care home evaluator manual (FCCH EM) Policy 102417.



LPA provided the Community Care Licensing website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised licensee of their responsibility to stay current in regards to new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws childcareadvocatesprogram@dss.ca.gov.

Exit Interview were conducted.

Effective today 8/28/2020 applicant is a license to serve up to either 14 children, (WHEN THERE IS AN ASSISTANT PRESENT), 12 children -No more than 4 infants. Capacity 14 - No more than 3 infants. 1 Child in Kindergarten or Elementary school and 1 child at least age 6.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Katrina OwensTELEPHONE: 916-263-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2020
LIC809 (FAS) - (06/04)
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