343618277-11-15-2019-03-CC-RPIS-BHXQJB-20191115111229

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343618277
Report Date: 11/15/2019
Date Signed: 11/15/2019 11:12:40 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:	KUBRAKOV, ANGELINA		FACILITY NUMBER:	343618277
ADMINISTRATOR:	KUBRAKOV, ANGELINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 459-7273
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95827
CAPACITY:	14	CENSUS: 2	DATE:	11/15/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Angelina Kubrakov		TIME COMPLETED:	11:15 AM

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) Pitts met with licensee Angelina Kubrakov for the purpose of an annual random inspection. The facility’s hours of operation are 6AM to 6PM Monday – Friday. The facility’s annual fees are current. Upon arrival, Licensee, 2 day care children, and Licensee’s assistant was present during the 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 include the upper level of the home. LPA observed a working phone, 3A40BC fire extinguisher and first aid kit. LPA observes functioning smoke and carbon monoxide detectors. Licensee stated that the smoke and carbon monoxide detectors are combined. The stairs in the home are appropriately barricaded. Per licensee, there are no weapons in the home. No children were observed in parked cars. LPA observed a pool fully enclosed by a fence at least 6 ft in height; In addition, the gate swings away from the pool, self-closes and has a self-latching device located no more than six inches from the top of the gate. Toxic and hazardous items are inaccessible to children. Safe toys were observed. Licensee states that the glass barricade on the fireplace does not get hot to touch. Licensee does not currently provide Incidental Medical Services (IMS). For IMS information, licensee was advised to see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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. Report continued on 809-C

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Rosie Pitts	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019

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: KUBRAKOV, ANGELINA	FACILITY NUMBER: 343618277
	VISIT DATE: 11/15/2019

NARRATIVE

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A sample of staff and children's records were reviewed. Required postings, a current roster, disaster drill log and proof of immunization's were observed. Current EMSA Certified pediatric CPR and first aid certification was verified and expires: 6/2020. AB 1207 Mandated Reporter Training was verified and expires 03/2020. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/ The licensee understands that the training must be completed every two years and proof of completion must remain in the facility’s file.

LPA discussed and provided Safe Sleep in Child Care and Effects of Lead Exposure brochures. LPA advised Licensee to distribute the brochures to parents. LPA provided the following link:http://www.cdss.ca.gov/inforesources/Community-Care-Licensing/subscribe for the Licensee to subscribe to the distribution list and receive Quarterly Updates.

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.CCLD.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 3 years for public review upon request.

In the areas that were evaluated, no Title 22 deficiencies were cited.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Rosie Pitts	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019

LIC809 (FAS) - (06/04)

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