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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001337
Report Date: 01/22/2020
Date Signed: 01/22/2020 11:24:41 AM

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:GOLDENSHTEYN, LILIANA R.FACILITY NUMBER:
384001337
ADMINISTRATOR:GOLDENSHTEYN, LILIANA R.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 681-1571
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:14CENSUS: 9DATE:
01/22/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Liliana GoldenshteynTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA), Van conducted an unannounced annual inspection and met with Licensee, Liliana Goldenteyn. The purpose of the inspection was explained and granted entry to the home by the licensee. Present in the facility are 9 children, and 2 helpers with the licensee (6 preschoolers and 3 infants). This is a two-story single-family house. Licensee owns this house. Daycare areas are on the ground floor including the playroom, kitchenette, the nap room, the bathroom and the backyard. The off-limit areas are the garage and the entire second-floor level. Days and operation hours are 7:30 am - 6:00 pm, Monday - Friday. Per Licensee, sick children will be separated from the group and will be waited in the nap room for the parent to pick up.

LPA and licensee inspected the daycare areas for health and safety hazards. During the inspection, LPA observed the following: The daycare 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, 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 or weapons in the home. The licensee stated she has a dog, and it is situated in the off-limit second-floor level. LPA observed no pools, spas, or other bodies of water on the premises. At 9:45 am, LPA observed in the bathroom, the cleaning products under the sink are inaccessible to daycare children. The licensee immediately has the helper removed all cleaning products and stored in an area that is inaccessible to children. LPA observed licensee had posted all the required forms (i.e., License, Notification of Parent's Rights, Notification of Personal Rights, and Emergency Disaster Plan). During the inspection, Licensee was not able to present a log or documentation of the fire and earthquake drill. During records review, LPA observed multiple children records were missing Parents Rights forms, Consent for medical treatment, and both helpers missing immunization records. All staff have vaild Pediatric FirstAid and CPR.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon VanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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: GOLDENSHTEYN, LILIANA R.
FACILITY NUMBER: 384001337
VISIT DATE: 01/22/2020
NARRATIVE
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During the inspection, the following was discussed with the licensee.
*Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website.
*Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com)
*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 given information regarding 'Safe Sleep' practices.
*LPA discussed the Family Child Care Home checklist and provided the checklist to the licensee as a reference for future inspection guide.

See 809D for deficiencies that were 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: 01/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: GOLDENSHTEYN, LILIANA R.
FACILITY NUMBER: 384001337
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2020
Section Cited

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102417 Operation of a Family Child Care Home (g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to:
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(9)Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A)Each family child care home shall conduct fire drills and disaster drills at least once every six months.(1)The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home. This requirement is not met as evidenced by: Based on observation and records reviewed today, Licensee does not fulfil the requirement of conducting and logging fire drill once every six months. This poses a potential health and safety risk to the children in care
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Type B
02/14/2020
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
Continue below...
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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. C1,C2, and C3,C4,C5,C6,C7, and C8 files were missing the parent's rights form. This poses a potential health and safety risk to childen 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: 01/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: GOLDENSHTEYN, LILIANA R.
FACILITY NUMBER: 384001337
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2020
Section Cited

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102418- Immunization. (g) Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
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(1)This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home. This requirement is not met as evidenced by records reviewed. C2, C3,C6,and C8 did not have complete immunization cards or the cards were left blank. Not having Immunization card for each child in care presents a potential Health and Safety risk.

Children need updated immunization records. See LIC 811 dated 2/14/20 for a list of children's names.
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Licensee and staff shall provide proof of immunization for all staff by the due date 02/14/20.
Type B
02/14/2020
Section Cited

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1596.7995 H&S 1596.7995(a)(1): Staff Immunization:
Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles.
Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement was not met as evidenced by records review, S1 and S2 did not have Immunization records in file. This poses a potential health and safety risk 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: 01/22/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4