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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618471
Report Date: 05/21/2019
Date Signed: 05/21/2019 11:04:47 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:CHERNIKOVA, SVETLANAFACILITY NUMBER:
343618471
ADMINISTRATOR:CHERNIKOVA, SVETLANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 217-2737
CITY:SACRAMENTOSTATE: CAZIP CODE:
95842
CAPACITY:14CENSUS: 3DATE:
05/21/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Svitlana ChernikovaTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Tanya Washington met with Licensee, Svitlana Chernikova for the purpose of an unannounced annual random inspection. LPA observed care and supervision of three preschool age children. Licensee's adult son was also present in the home. All individuals subject to criminal background review have obtained a criminal record clearance. Facility operates Monday- Friday from 7 AM to 6 PM.

Off limit areas include: three bedrooms in the hallway on the left, garage, master bedroom/ bath and fenced side yard on the left. The main area for care is the living room, both dining rooms and two bedrooms. Licensee utilizes the bedrooms mainly for napping and on occasion for play. 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. There is no fireplace in the home.

A health and safety inspection was conducted in all areas accessible to children. Licensee utilizes the backyard for outdoor play, LPA observed a wooden play structure with a slide, climbing area and swings, the swing set appeared to be in good condition.

Children's records were reviewed. LPA observed signed Parent's Rights form (LIC995A) and Consent for Medical Treatment (LIC627) in children's files. Current pediatric CPR and first aid certification was verified for Licensee (exp. date 09/2019).

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: 05/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
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: CHERNIKOVA, SVETLANA
FACILITY NUMBER: 343618471
VISIT DATE: 05/21/2019
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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

Proof of required vaccines for Licensee have been verified. LPA discusses proposed Safe Sleep Concepts and provided a copy of the hand out to Licensee.

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: 05/21/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2019
LIC809 (FAS) - (06/04)
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