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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618277
Report Date: 10/12/2022
Date Signed: 10/27/2022 11:42:18 AM


Document Has Been Signed on 10/27/2022 11:42 AM - 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:KUBRAKOV, ANGELINAFACILITY NUMBER:
343618277
ADMINISTRATOR:KUBRAKOV, ANGELINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 459-7273
CITY:SACRAMENTOSTATE: CAZIP CODE:
95827
CAPACITY:14CENSUS: 0DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Angelina KubrakovTIME COMPLETED:
11:45 AM
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On Thursday, October 27, 2022 at 10:45 AM, Licensing Program Analysts (LPA) Amanda Sutter and Soleil Marx met with Licensee, Angelina Kubrakov, for the purpose of an unannounced annual inspection. Licensee’s husband was also present. All individuals subject to criminal background review have obtained a criminal record clearance. No children were present in the facility. Facility hours of operation are 24/7.

A health and safety evaluation was conducted in all areas accessible to children. Off-limit areas include: garage, entire upstairs, and bedroom 4. Licensee acknowledged that children may never enter these off-limit areas. LPAs observed that the facility is clean, safe, sanitary, and in good repair. LPAs observed a functioning smoke detector and a full 3A10BC fire extinguisher. The facility has adequate toys that appear to be safe for children to use. The licensee stated there are no weapons or poisons in the home. The backyard is fenced. There is a pool which is fully fenced, and has a self-latching gate that swings away from the pool. LPA observed a fireplace barricaded according to regulation.

LPA reviewed five children’s files. All files appeared to be complete. Required postings and the children’s roster were observed. Fire drill log was observed. The last fire drill was conducted on 9/30/2022. Licensee’s CPR/First Aid card has an expiration date of 9/2022. Licensee stated that she is enrolled in a course that will take place on 11/4/2022. Licensee’s mandated reporter expires 1/2024.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPAS also informed licensee 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.
PAGE 1. REPORT CONTINUES ON LIC809-C
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Amanda SutterTELEPHONE: (916) 261-8918
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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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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: 10/12/2022
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Incidental Medical Service (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

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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/process.

A notice of site visit was given and must remain posted for 30 days. Based on the inspection, no citations have been issued. Exit interview conducted and report was reviewed with the licensee Angelina Kubrakov.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Amanda SutterTELEPHONE: (916) 261-8918
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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