343618461-2-20-2020-03-CC-MBED-BLYV2B-20200220150251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343618461
Report Date: 02/20/2020
Date Signed: 02/20/2020 03:02:57 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:	STUKOVA, INNA		FACILITY NUMBER:	343618461
ADMINISTRATOR:	STUKOVA, INNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 475-0214
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95841
CAPACITY:	14	CENSUS: 1	DATE:	02/20/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Inna Stukova		TIME COMPLETED:	03:30 PM

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) Marea Behvand met with licensee, Inna Stukova, for the purpose of an unannounced annual random inspection. The licensee's two minor children were also present upon arrival. The licensee's minor child translated for LPA and the licensee. All individuals subject to criminal background review have obtained a criminal record clearance. A health and safety inspection was conducted in all areas accessible to childrem. Off-limits areas include Bedroom #1/en-suite bathroom, Bedroom #2, Bedroom #3, Master bedroom #4/en-suite bathroom, laundry room, backyard, and garage. LPA observed a working phone, 3A40BC fire extinguisher, and dual 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. The fireplace in the home was appropriately barricaded to prevent access by children. Children’s files were reviewed. A current roster is being maintained and fire and disaster drills are documented. Preventative health training, current pediatric CPR and first aid certification was verified and expires 5/22/2020. Report continues on 809-C.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Marea Behvand	TELEPHONE: (916) 216-7793
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

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: STUKOVA, INNA	FACILITY NUMBER: 343618461
	VISIT DATE: 02/20/2020

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 form.

Lead disclosure was provided and safe sleep regulations were discussed.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Marea Behvand	TELEPHONE: (916) 216-7793
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

LIC809 (FAS) - (06/04)

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