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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001243
Report Date: 11/13/2019
Date Signed: 11/13/2019 04:14:26 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GOLDFELD, GALINA & GOLDFELD, VLADIMIRFACILITY NUMBER:
384001243
ADMINISTRATOR:GOLDFELD, GALINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 731-5943
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:14CENSUS: 8DATE:
11/13/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Galina GoldfeldTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Van conducted an unannounced annual inspection and met with Licensee, Galina Goldfeld. LPA rang the doorbell several times, no one was answering the door. LPA called the phone number that was listed on licensee's profile, licensee picked up the phone. LPA explained the purpose of the inspection, licensee told LPA to wait. Approximately 4 minutes later licensee opened the door. The purpose of the inspection was again explained and was granted entry to the home by licensee. Present in the facility is 8 children with licensee and 2 helpers (2 infants and 6 preschools). Licensee husband/co-licensee Vladimir Goldfeld came home during the inspection. This is a two story single family house. Day care areas are on the ground floor level including: the playroom, bedroom, study room, bathroom and the backyard. Off-limit areas are the garage and the entire second level floor.

LPA and Licensee inspected the day care areas for health and safety hazards. LPA observed the following: Day-care area is clean, orderly, and equipped with age appropriate toys and equipment for the children. The home has adequate lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged fire extinguisher. First aid supplies are available for children. Per licensee there are no firearms, weapons or pets in the home. LPA observed no pools, spas or other bodies of water on the premises. All poisons, detergents, or cleaning products are inaccessible to day care children and stored in the garage. LPA observed licensee has posted all the required forms (i.e. License, Notification of Parent's Rights, Notification of Personal Rights, and Emergency Disaster Plan). Fire drills are conducted and documented accordingly. At 3:30P.M., LPA reviewed children and staff records, LPA found C2,C4,C6, and C8 parents' rights form were missing parent's signature. Licensee Pediatric FirstAid & CPR will expire on 12/9/2020.

During inspection the following were discussed with licensee.
*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
*Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com)
*Licensee was given information regarding ‘Safe Sleep’ practices.

See LIC 809D for deficiency that was observed today. A copy of this report was reviewed and provided to the licensee. This report will be kept in the facility file and will be made available for public review upon request. Notice of Site Visit was observed to be posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2019
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GOLDFELD, GALINA & GOLDFELD, VLADIMIR
FACILITY NUMBER: 384001243
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2019
Section Cited

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102419 Admission Procedures and Parental and Authorized Representative's Rights. (d)At the time of acceptance of each child into care, the licensee shall provide the child's parent or
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authorized representative with a copy of the notice Family Child Care Home Notification of Parents’ Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).(1)The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver Background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05). This requirement is not met as evidenced by records review. Records review revealed that C2,C4,C6, and C8 did not have parent signatures. This poses a potential health and safety risks to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2019
LIC809 (FAS) - (06/04)
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