343618620-10-28-2019-03-CC-TWAN-BHDMVH-20191028095647

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343618620
Report Date: 10/28/2019
Date Signed: 10/28/2019 09:56:58 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:	STEPANOVA, ANNA		FACILITY NUMBER:	343618620
ADMINISTRATOR:	STEPANOVA, ANNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 339-1356
CITY:	ANTELOPE	STATE: CA	ZIP CODE:	95843
CAPACITY:	14	CENSUS: 3	DATE:	10/28/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Anna Stepanova		TIME COMPLETED:	10:00 AM

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) Tanya Washington met with Licensee, Anna Stepanova for the purpose of an unannounced annual/random inspection. LPA observed care and supervision of two infants and one preschool age child. All individuals subject to criminal background review have obtained a criminal record clearance. Facility operates Monday- Friday from 5:00 AM to 6:00 PM. A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include entire second floor, downstairs bedroom (mother's bedroom), garage and left side yard. 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. Kitchen knifes are properly stored in the upper kitchen cabinet; medications are also stored out of children's reach in the kitchen pantry. Safe toys and comfortable accommodations were observed. LPA observed an updated children's roster and an updated fire drill log. The fireplace located in the home is properly barricaded. Stairs leading to the second floor is barricaded with a safety gate. Three Children's records were reviewed, Child #3 did not have an immunization record. LPA Licensee's CPR and First aid certification is valid until 04/26/2020. Licensee provided verification of her shot record. LPA verified that the annual Licensing fees are current. Report continues on LIC809-C.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2019

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: STEPANOVA, ANNA	FACILITY NUMBER: 343618620
	VISIT DATE: 10/28/2019

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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

LPA reviewed Safe Sleep Regulation Concepts and appropriate infant equipment used in child care homes, LPA also provided a brochure regarding Lead Exposure and explained that each parent must be provided a copy of the brochure.

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.

Title 22 deficiency is cited on the subsequent page of this report LIC809D. Appeal Rights were provided and an exit interview was conducted. A Notice of Site Visit was posted and must remain posted for 30 days.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2019

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: STEPANOVA, ANNA	FACILITY NUMBER: 343618620
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/02/2019 Section Cited	1 2 3 4 5 6 7	Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. This requirement is not met as evidenced; LPA observed that Child #3 is missing their immunization record. This is a potential risk to the health and safety of children in care.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2019

LIC809 (FAS) - (06/04)

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