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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618458
Report Date: 08/06/2019
Date Signed: 08/06/2019 01:24:29 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:SHEVCHUK, LILIYAFACILITY NUMBER:
343618458
ADMINISTRATOR:SHEVCHUK, LILIYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 514-3540
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:14CENSUS: 10DATE:
08/06/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Liliya ShevchukTIME COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tanya Washington met with Licensee, Liliya Shevchuk for the purpose of an unannounced annual/random inspection. LPA observed 10 napping children supervised by Licensee and her adult son. Also present is Licensee's spouse and adult daughter who was visiting. All individuals subject to criminal background review have obtained a criminal record clearance. Facility operates Monday- Friday from 6 AM to 5:30 PM.

A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include garage and garden area. 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, parents enter the home through side gate which leads to the play area. LPA reviewed children's roster and observed and updated fire drill log.

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 05/15/2021). 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)
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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: SHEVCHUK, LILIYA
FACILITY NUMBER: 343618458
VISIT DATE: 08/06/2019
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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.



No deficiencies are observed during the annual inspection.
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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