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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618307
Report Date: 08/06/2019
Date Signed: 08/06/2019 12:20:44 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:KRYUCHKOV, IRINAFACILITY NUMBER:
343618307
ADMINISTRATOR:KRYUCHKOV, IRINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 489-8962
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:14CENSUS: 12DATE:
08/06/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Irina KryuchkovTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tanya Washington met with Licensee, Irina Kryuchkov for the purpose of an unannounced annual/random inspection. LPA observed care and supervision of 12 children supervised by the Licensee, also present is a dance/music teacher who comes to the facility twice a week for 1 hour lesson. Licensee did not have a qualified assistant and is out of ratio by 4 children.
Licensee operates Monday-Friday from 7 AM to 10 PM, times vary depending on the need of families. LPA toured all areas of the home accessible to children in care.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include entire second floor and garage. LPA observed a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. There are no accessible bodies of water on the premises. Toxic and hazardous items are inaccessible to children. Safe toys and comfortable accommodations were observed. Outdoor play space is fenced.

Children's records were reviewed. Emergency information and required immunization records were on file. Current pediatric CPR and first aid certification was verified for Licensee (exp. date 06/11/20). LPA reviewed Licensee's vaccines, she declines the influenza vaccine.

LPA verified that the annual Licensing fees are current.


Report continues on LIC809-C.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: KRYUCHKOV, IRINA
FACILITY NUMBER: 343618307
VISIT DATE: 08/06/2019
NARRATIVE
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This provider is currently not providing IMS services to children in care. 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 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.CDSS.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 three years for public review upon request. The licensee's signature on this form acknowledges receipt of this report.



Upon receipt, licensee shall post and provide copies of this licensing report to parents/ guardians of children who are currently enrolled as well as parents/ guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must acknowledge receipt of this report and citation by signing a LIC 9224, “ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS”. A copy of this form should be placed in each child file upon receipt from parent.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2019
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: KRYUCHKOV, IRINA
FACILITY NUMBER: 343618307
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2019
Section Cited
CCR
102416.5(e)
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If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c). This requirement is not met as evidenced; Licensee had 12 children present while her qualified assistant was out. This is an immediate risk to the health and safety of children in care.
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Licensee stated she was not aware of the regulation and assumed that while the music/dance teacher was instructing a lesson she was within regulation requirement. LPA went over capacity limitations for both small and large limitation.
LPA will return to clear citation.
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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: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2019
LIC809 (FAS) - (06/04)
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