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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618307
Report Date: 08/16/2019
Date Signed: 08/16/2019 10:46:12 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:KRYUCHKOV, IRINAFACILITY NUMBER:
343618307
ADMINISTRATOR:KRYUCHKOV, IRINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 489-8962
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:14CENSUS: 4DATE:
08/16/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Irina KryuchkovTIME COMPLETED:
11:05 AM
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Licensing Program Analyst Tanya Washington met with Licensee Irina Kryuchkov for a plan of correction inspection to clear Type A deficiency which was cited on 08/06/2019 for having too many children with one staff (out of ratio). During today's inspection LPA observed 4 preschool children supervised by the Licensee. Deficiency cited during the last inspection is cleared today.

LPA observed signed LIC9224 forms in children's files.

Notice of site visit posted. No deficiencies are observed today.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2019
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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