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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623673
Report Date: 09/14/2020
Date Signed: 09/14/2020 04:26:40 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:DYACHISHIN, GALINAFACILITY NUMBER:
343623673
ADMINISTRATOR:DYACHISHIN, GALINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 390-8744
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:14CENSUS: 0DATE:
09/14/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Galina DyachhishinTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Lea Habtom met with licensee Galina Dyachishin for a change of location inspection. Also present today was licensee’s daughter, Tanya Dyachishin. LPA toured the 3 bedrooms, 3 bathroom one story home inside and out. Family members residing at the home are 2 adults; Galina and Peter Dyachishin. LPA explained that any new residents that move into the home must be fingerprint cleared and the Licensing Agency must be notified prior to them residing in the home. LPA received confirmation for control of property. Licensee will obtain $300,000 liability insurance and is aware to have parents sign affidavit if no insurance is purchased. Licensee has certificates of completion for 16 hours of health and safety training including CPR and First Aid with expiration date of 4/2021 and mandated reporter expires 10/2020. All adult residing in the home have received criminal record clearances and proof of TB clearance. LPA reminded licensee of the applicable Civil Penalty per person for those adults, including your own child, who have not received fingerprint clearances, are not associated to the license, come in contact with and or provide care and supervision to the children.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, to obtain updated licensing information, new regulations and access forms. LPA advised the licensee of their responsibility to stay current regarding new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws childcareadvocatesprogram@dss.ca.gov.

Licensee understands that prior to making alterations or additions to the home or grounds, the licensee shall notify the Department of the proposed changes. There is no shed in the backyard. Off-limit areas include: the backyard attached to the patio, garage, the entire front house including all bedrooms, bathrooms & kitchen. Licensee understands that children may never enter these off-limit areas. The backyard is fenced and licensee understands that areas that are not fenced requires 100% supervision. There are no bodies of water. LPA reviewed the fire drill requirements.

Continued on the following page LIC 809-C

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
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: DYACHISHIN, GALINA
FACILITY NUMBER: 343623673
VISIT DATE: 09/14/2020
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The fireplace contains a screen. Licensee stated there are no weapons in the home. LPA observed a 2A10BC fire extinguisher.

LPA observed a working carbon monoxide detector and smoke detector was tested and observed to be working. Hazardous cleaning compounds are inaccessible to children. Sharp utensils and Medications are inaccessible to children.

Effective September 14, 2020, licensee is approved for a large license to serve up to either 14 children, two (2) of which must be at least 6 years of age and no more than three (3) may be infants; or 12 children, four (4) of which may be infants. Infants are children under the age of 2.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
LIC809 (FAS) - (06/04)
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