343623721-9-28-2020-03-CC-TWAN-BTVRLJ-20200928130714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343623721
Report Date: 09/28/2020
Date Signed: 09/28/2020 01:07:59 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:	DERIABINA, NATALIIA		FACILITY NUMBER:	343623721
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	09/28/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Nataliia Deriabina		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 contacted Applicant Nataliia Deriabina for the purpose of a scheduled announced pre-licensing/ change of location tele-inspection. Due to COVID19 pandemic, a tele- inspection is being conducted via Facetime. The applicant is currently licensed at facility #343622260. Applicant submitted an application for a small license. During today's virtual inspection no day-care children were present in the home. All individuals subject to criminal background review have obtained a criminal record clearance. Applicant plans to operate Monday- Friday from 7 AM to 6 PM. Applicant's spouse owns the home and a copy of the mortgage statement has been submitted. A health and safety inspection was conducted inside and out. This is single story facility which includes 4 bedrooms, 2 bathrooms, a living room, dining room, kitchen, garage and laundry room. The off-limit areas in the home will consist of Licensee's master bedroom, her daughters rooms, garage and laundry room. Off-limit areas will remain inaccessible to children by closed doors and/or supervision. Applicant plans to utilize the living room, kitchen/dining area, first bedroom in the hallway and backyard for day-care use. The fireplace located in the dining room is properly barricaded. Toxic and hazardous items are inaccessible to children and are stored out of children's reach. Sharp knifes are stored out of children's reach in the kitchen area. Medication is stored out of children's reach on top of the kitchen refrigerator. A functioning smoke and carbon monoxide detector are functioning in the home. LPA also observed a functioning 2A10BC fire extinguisher. LPA observed all required licensing postings along with COVID19 posters. 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: 09/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2020

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: DERIABINA, NATALIIA	FACILITY NUMBER: 343623721
	VISIT DATE: 09/28/2020

NARRATIVE

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Applicant Deriabina has completed the required Preventative Health and Safety course along with the "stand alone" Lead Prevention training. Applicant has a current EMSA certified CPR and First Aid card which expires 11/16/2021. LPA observed that the weapon is stored according to Title 22 Regulations. There are no bodies of water on the premises. Applicant was encouraged to maintain supervision at all times. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed.

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

This facility evaluation report was reviewed and discussed with the Applicant. LIC311D, records, postings, and reporting requirements were discussed. LPA discussed supervision, personal rights, criminal record clearances, ratios and capacity, and maintaining buildings and grounds. Applicant was encouraged to visit the Department's website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

As of today September 28, 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.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2020

LIC809 (FAS) - (06/04)

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