343618483-2-7-2023-03-CC-ASUR-CNTMP4-20230207084631

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343618483
Report Date: 02/06/2023
Date Signed: 02/07/2023 08:46:55 AM

Document Has Been Signed on 02/07/2023 08:46 AM - It Cannot Be Edited

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:	GOLUB, INNA		FACILITY NUMBER:	343618483
ADMINISTRATOR:	GOLUB, INNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 844-5042
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95842
CAPACITY:	14	CENSUS: 4	DATE:	02/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Inna Golub		TIME COMPLETED:	02:30 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	On Monday, February 6, 2023, Licensing Program Analyst (LPA) Amanda Sutter met with Licensee, Inna Golub, for the purpose of an unannounced annual inspection. All individuals subject to criminal background review have obtained a criminal record clearance. Upon arrival, LPA observed licensee supervising 4 children. Licensee's minor child was also present. Facility hours of operation are Monday through Friday from 7:30 AM to 5:00 PM. A health and safety evaluation was conducted in all areas accessible to children. Off-limit areas include: entire upstairs. Licensee acknowledged that children may never enter these off-limit areas. LPA observed that the facility is clean, safe, sanitary, and in good repair. LPA observed a functioning smoke detector, carbon monoxide detector, and a full fire extinguisher that meets regulation. The facility has adequate toys that appear to be safe for children to use. The licensee stated there are no weapons or poisons in the home. LPA spoke with licensee regarding storing cleaning products out of reach of children. The backyard is fenced. LPA observed a fireplace and stairs to be barricaded according to regulation. LPA reviewed four children’s files which were observed to be complete. Required postings and the children’s roster were observed. A current roster is being maintained and fire drills are documented. The last fire drill was conducted 1/9/2023. Licensee’s CPR/First Aid card expired in 2021. Licensee is exempt from Mandated Reporter Training due to language barrier. Licensee understands that trainings must be completed every two years. LPA verified that the annual fees are current. LPAs provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the licensee can request to be added to the distribution list to receive Quarterly Updates. *PAGE 1. REPORT CONTINUES ON LIC809-C*

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Amanda Sutter	TELEPHONE: (916) 261-8918
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

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: GOLUB, INNA	FACILITY NUMBER: 343618483
	VISIT DATE: 02/06/2023

NARRATIVE

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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Service (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

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

A notice of site visit was given and must remain posted for 30 days. Based on the inspection, one Type B citation has been issued. Exit interview conducted and report was reviewed with the licensee Inna Golub.

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Amanda Sutter	TELEPHONE: (916) 261-8918
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/07/2023 08:46 AM - It Cannot Be Edited

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: GOLUB, INNA	FACILITY NUMBER: 343618483
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee's CPR/First Aid certification expired in 2021. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2023
	Plan of Correction
1 2 3 4	Licensee will submit proof of enrollment in a CPR/First Aid course by date listed above

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Amanda Sutter	TELEPHONE: (916) 261-8918
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023

LIC809 (FAS) - (06/04)

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