343622238-12-12-2022-03-CC-ABLI-CM2VJG-20221212152842

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343622238
Report Date: 12/12/2022
Date Signed: 12/12/2022 03:29:01 PM

Document Has Been Signed on 12/12/2022 03:29 PM - 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:	VOROBYEV, TATYANA		FACILITY NUMBER:	343622238
ADMINISTRATOR:	VOROBYEV, TATYANA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 239-5794
CITY:	ANTELOPE	STATE: CA	ZIP CODE:	95843
CAPACITY:	14	CENSUS: 13	DATE:	12/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Tatyana Vorobyev		TIME COMPLETED:	03:45 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) Amanda Blesi met with Licensee, Tatyana Vorobyev for the purpose of an unannounced required 1-year inspection. Also present was licensee's daughter in law (assistant) Anastia Demenko and licensee's spouse Sergio. At 2:40 PM LPA observed a total census of 13 children including 1 school age child. No infants were present today. At 2:45 PM, Licensee guided LPA on a tour of the facility, and a health and safety inspection was conducted in all areas accessible to children. Off-limits areas include entire upstairs. Licensee acknowledged children may never enter the off limit areas. LPA observed the required postings, a working phone, a 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Per Licensee, there are no weapons in the home. There is an in-ground pond on the property which is surrounded by a see-through iron fence that is at least 5 feet high. LPA observed the gate to self-close and self-latch. There are no windows or doors that provide direct access into the pond area. Toxic and hazardous items are inaccessible to children. Fireplace is barricaded to prevent access by children. Stairs were barricaded to prevent access when children under 5 are present. Outdoor play space is fenced. 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. A current roster is being maintained and fire and disaster drills are documented. Current CPR and First Aid certification was verified and expires 2/2023. LPA observed AB1207 Mandated Reporter Certificate for licensee which expires 2/2023. (Report continues on LIC809-C)

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda Blesi	TELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

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: VOROBYEV, TATYANA	FACILITY NUMBER: 343622238
	VISIT DATE: 12/12/2022

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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 Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided an updated Plan of Operation that includes 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

No Title 22 deficiencies were cited during today’s inspection.

Exit interview conducted and report was reviewed with the licensee Tatyana Vorobyev. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amanda Blesi	TELEPHONE: (916) 208-3427
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC809 (FAS) - (06/04)

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