343623526-4-22-2020-03-CC-TWAN-BNWS5M-20200422133436

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343623526
Report Date: 04/22/2020
Date Signed: 04/22/2020 01:35:09 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:	SHEVCHUK, OLENA		FACILITY NUMBER:	343623526
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	04/22/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Olena Shevchuk		TIME COMPLETED:	02:00 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 April 22, 2020 at approximately 12:00 PM, Licensing Program Analyst (LPA) Tanya Washington contacted Applicant Olena Shevchuk to conduct an announced Pre-Licensing Tele Inspection. The Tele Visit inspection is being conducted over Face-Time due to COVID-19 pandemic. All individuals subject to criminal background review have obtained a criminal record clearance. The visit was conducted in Russian language. Applicant is applying for a Small Family Child Care License. Applicant rents the home and a copy of the rental agreement was submitted with the application. Applicant stated that the landlord has given her a verbal permission to provide care up to 8 children, however she has not obtained the required signed form (LIC9149). Until the form is obtained Applicant can only provide care to six children including her own related children. A health and safety inspection was conducted inside and outside of the home. This facility is a single story home with 4 bedrooms, 2 bathrooms. The home has an unfenced front yard, a living room, dining room, kitchen, play room, garage, and a fenced backyard. Applicant stated that the off-limit areas will be: daughter's bedroom, son's bedroom, garage and laundry room. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. The fireplace located in the living room is properly barricaded. Toxic and hazardous items are inaccessible to children. Functioning smoke and carbon monoxide detectors, and a 2A10BC fire extinguisher were observed in the home. Applicant was encouraged to check the equipment at least once every six months. Current pediatric CPR and first aid training was verified, it expires 11/16/2021. Applicant completed AB1207 Mandated Reporter training through Child Action on 09/19/2019. Applicant stated there are no weapons in the home. There is no pool or bodies of water on the premises. Report continued on the following page LIC809C.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2020

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: SHEVCHUK, OLENA	FACILITY NUMBER: 343623526
	VISIT DATE: 04/22/2020

NARRATIVE

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Applicant understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Applicant understands that if an assistant is hired they must have required vaccines and licensing forms signed. (The list of required documents and vaccines was provided and discussed).

Applicant understands that licenses are not transferable, and once licensed, Applicant must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if they move and want to continue to provide care, they must submit a change of location application and have the new home inspected.

Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within seven days to remain in compliance.

Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction. Applicant understands that if they want to make any off-limit area an ON-limits area, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the area.

Applicant understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to three years. Applicant understands that their License, Emergency Disaster Plan, and the Parents Rights Poster must be posted in the home.

Incidental Medical Services (IMS) policy was discussed. Applicant was encourages to develop a plan for providing IMS.

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

Records, postings and reporting requirements were discussed. LIC311D was provided and discussed. Report continued on the following LIC809C page.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2020

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: SHEVCHUK, OLENA	FACILITY NUMBER: 343623526
	VISIT DATE: 04/22/2020

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Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes. LPA provided applicant with the e-mail address: childcareadvocatesprogram@dss.ca.gov, in order to be added to the list for the quarterly newsletter and other provider information.

*LPA discussed and e-mailed a Provider Information Notice (PIN) 20-06 CCP which discusses guidance and practices regarding social and physical distancing for providers to prevent exposure to COVID-19 while providing care for children.

As of today April 22, 2020 facility is approved for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only; or up to 8 children with no more than 2 infants, with 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.
***LANDLORD CONSENT REQUIRED TO CARE FOR TWO ADDITIONAL CHILDREN***

This facility evaluation report was reviewed and discussed with the applicant. In lieu of Applicant's signature, LPA Washington is e-mailing the report to Applicant. Applicant agrees to read and respond to the e-mail as proof of receipt.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2020

LIC809 (FAS) - (06/04)

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