343624017-11-29-2021-03-CC-TWAN-C98U4E-20211129141502

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343624017
Report Date: 11/29/2021
Date Signed: 11/29/2021 02:15:14 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:	LEVENSON, POLINA		FACILITY NUMBER:	343624017
ADMINISTRATOR:	LEVENSON, POLINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 588-7272
CITY:	NORTH HIGHLANDS	STATE: CA	ZIP CODE:	95660
CAPACITY:	14	CENSUS: 1	DATE:	11/29/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Polina Levenson		TIME COMPLETED:	02:30 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 November 29, 2021 at 12:30 PM, Licensing Program Analyst (LPA) Tanya Washington met with Applicant, Polina Levenson for an announced Pre-Licensing/ Change of location inspection, also present during the inspection is Applicant's daughter Anna Yakushenko. Applicant was previously licensed under facility #343623386. Applicant plans to operate Monday- Friday from 7 AM to 6 PM. Applicant and all adult residents have received a criminal background clearance and are associated to the facility. Applicant has submitted an application for a large license. on September 1, 2021, this facility was granted a fire clearance by Sacramento Country Department of Community Development Buildings Permit and Inspection. The condition of the clearance is that the Applicant is not allowed to use her garage for day-care. LPA and Applicant toured the single story home which has four bedrooms, two bathrooms, living room, dining room, kitchen, garage and fenced backyard. Applicant's spouse owns the home and control of property was provided with the application. Applicant does not have liability insurance and will have parents fill out an affidavit. Off-limit area will consist of master bedroom/ bathroom, Anna's room, office and garage. Applicant understands that children may never enter the off-limits areas of the home. Applicant plans to utilize the first bedroom on the left for napping purposes and the first bathroom on the right for day-care children. Applicant acknowledges she is required to notify licensing prior to making changes to off-limit areas so that they may be inspected for safety. 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: 11/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

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: LEVENSON, POLINA	FACILITY NUMBER: 343624017
	VISIT DATE: 11/29/2021

NARRATIVE

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LPA observed a carbon monoxide detector, a functional smoke detector and a 2A10BC fire extinguisher. Hazardous cleaning products and chemicals, knives, and medications are all stored inaccessible to children. Applicant understands that poisons must be locked.

Applicant is aware that 100% supervision must be maintained at all times when children are around bodies of water or in unfenced areas. Applicant stated there are no firearms in the home. There are no bodies of water on the premises.

Applicant has completed the required EMSA certified CPR and First Aid class which is valid until 01/25/2022. Applicant has completed the required Preventative Health and Safety course and her AB1207 Mandated Reporter certification is valid until 01/25/2022.

LPA discussed current COVID-19 guidelines, postings, and protocols. LPA discussed Type A and Type B citations, Zero Tolerance, and Civil Penalties. LPA discussed open door policy, supervision, fire drills, children’s personal rights, reporting requirements, and the smoking prohibition with the applicant. A current roster of children enrolled must be available and maintained for a period of three years, even after children are no longer in care.

Annual fees must be paid promptly and by the due date or late fees will be assessed. Applicant understands that the license is non-transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if she relocates and wants to continue to provide care, she must submit a change of location application and have the new home inspected.

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: 11/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

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: LEVENSON, POLINA	FACILITY NUMBER: 343624017
	VISIT DATE: 11/29/2021

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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.

LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the applicant can request to be added to the distribution list to receive Quarterly Updates. LPA provided form LIC311D and discussed the required forms for children's records, employee records, and forms required to be kept on file at the facility. LPA provided the Licensing Agency website (WWW.CCLD.CA.GOV), so that the applicant may obtain updated licensing information, regulations, PINs, and forms.

EFFECTIVE TODAY, 11/29/2021, 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.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya Washington	TELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021

LIC809 (FAS) - (06/04)

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