343618101-9-27-2022-03-CC-JGAG-CJNU9H-20220927152311

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343618101
Report Date: 09/27/2022
Date Signed: 09/27/2022 03:23:17 PM

Document Has Been Signed on 09/27/2022 03:23 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME:	PROTSYUK, ANNA		FACILITY NUMBER:	343618101
ADMINISTRATOR:	PROTSYUK, ANNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 761-4080
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95841
CAPACITY:	14	CENSUS: 0	DATE:	09/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Anna Protsyuk		TIME COMPLETED:	03:30 PM

NARRATIVE

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On September 27, 2022 at 2:00 PM, Licensing Program Analyst (LPA) Josiah Gathing met with licensee Anna Protsyuk for the purpose of an annual required one year inspection. The licensee’s husband and minor child were also in the home at the time of the LPA inspection. All individuals subject to criminal background review have obtained a criminal record clearance.

A health and safety evaluation was conducted in all areas accessible to children. Off limits areas consist of: Master Bedroom/Bathroom.

LPA observed a fully charged 2-A-10-BC fire extinguisher, first aid kit, and functioning smoke and carbon monoxide detectors. Per licensee, there are no weapons or poisons in the home. Sharp knives are stored in a kitchen cabinet out of children’s reach. LPA observed that the fireplace was not blocked by a screen or barrier during today’s inspection.

During file review, LPA observed all necessary Children’s documents. LPA observed a current children’s roster and fire drill log last updated July, 2022. LPA observed First Aid/CPR certificate valid through January 2024.

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 followinginformation regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA available at: http://wwwada.gov/childqanda.htm

CONTINUED ON LIC809-C…

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Josiah Gathing	TELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

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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Document Has Been Signed on 09/27/2022 03:23 PM - It Cannot Be Edited

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: PROTSYUK, ANNA	FACILITY NUMBER: 343618101
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(1)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above the fireplace was uncovered which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Licensee will provide LPA with proof of fire place screen or cover by the above POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Josiah Gathing	TELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

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: PROTSYUK, ANNA	FACILITY NUMBER: 343618101
	VISIT DATE: 09/27/2022

NARRATIVE

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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Licensee [or facility representative] was reminded that all adults 18 and over living or working in the honme, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPAs discussed the safe sleep regulations with licensee [or facility representative] and discussed the Child Care Licensing Safe Sleep webpage at http://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

A notice of site visit was given and must remain posted for 30 days. Exit interview was conducted and report was reviewed with the Licensee, Anna Protsyuk.

Deficiency is cited on the following LIC809D. Appeal Rights were provided.

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Josiah Gathing	TELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC809 (FAS) - (06/04)

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