343623526-10-22-2021-03-CC-TWAN-C82MTH-20211022095334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343623526
Report Date: 10/22/2021
Date Signed: 10/22/2021 09:53:37 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:	SHEVCHUK, OLENA		FACILITY NUMBER:	343623526
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 3	DATE:	10/22/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Olena Shevchuk		TIME COMPLETED:	10:30 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	On October 22, 2021 at 9:00 AM, Licensing Program Analyst (LPA) Tanya Washington met with Licensee Olena Shevchuk for an unannounced case management inspection to increase capacity to the maximum number of 14 children. Upon arrival, LPA observed care and supervision of two day-care children and Licensees own minor child. Facility hours and days of operation are Monday- Friday, from 7 AM to 10 PM. Licensee stated that she has verbally notified her landlord that she will be providing care to more children. Licensee understands that prior to enrollment of 13th and 14th child she must obtain her landlords signature on form LIC9149. Licensee also was informed that she would need to have a qualified assistant if additional children are enrolled. LPA discussed capacity options with and without an assistant and when the Licensee or the assistant are alone they divert to small license ratio requirements. On October 7, 2021, Sacramento Metropolitan Fire Department granted a fire clearance with no specific conditions. During today's inspection Licensee requested to update her off limit areas. The current off limit areas in the home are: four bedrooms, master bathroom, garage and laundry room. Licensee stated that she utilizes the play room which is located upon entry to the home, living room, dining room and fenced backyard. Licensee understands that children may not have access to the off limit areas of the home. LPA observed a large netted trampoline in the backyard, Licensee was advised to follow manufacturing guidelines and ensure that the trampoline is always in good repair. Continued on LIC809C

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

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: 10/22/2021

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Licensee's CPR and First Aid is valid until 10/2023. Licensee has completed required Mandated Reporter training on 10/13/2021. She is aware to renew the certification every two years.

EFFECTIVE TODAY, 10/22/2021 THE FACILITY IS LICENSED TO SERVE A MAX. CAP OF 12 (WHEN THERE IS AN ASSISTANT PRESENT): WITH NO MORE THAN 4 INFANTS.
OR MAX CAP 14 - NO MORE THAN 3 INFANTS. 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6. Licensee acknowledges that the Landlord consent is required to care for 13th and 14th child.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC809 (FAS) - (06/04)

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