384001641-10-6-2022-05-CC-BVAN-CJXVZV-20221006165321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384001641
Report Date: 10/06/2022
Date Signed: 10/06/2022 04:53:30 PM

Document Has Been Signed on 10/06/2022 04:53 PM - It Cannot Be Edited

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:	SHUBAYEV, ALENA		FACILITY NUMBER:	384001641
ADMINISTRATOR:	SHUBAYEV, ALENA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 564-5883
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94116
CAPACITY:	14	CENSUS: 4	DATE:	10/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Elena Shubayev		TIME COMPLETED:	05:00 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	Licensing Program Analyst (LPA) Van performed an annual mandatory inspection, which included checking the interior and exterior of the facility and discussing the required childcare paperwork with the Licensee. The purpose of the inspection was explained, and granted entry to the home by the Licensee. No childcare children are present at home today except for the Licensee's four minor children. Every adult living and working in the home has a criminal record clearance. Day Care is on the ground floor, including a playroom, two nap rooms, a dining/kitchen area, the bathroom, and 1/2 of the backyard. Off Limit Area is the entire upstairs and the garage. During the inspection, the Licensee requested to make both nap rooms off-limit areas. LPA reminded the Licensee if she decided to use the two nap rooms again, Licensee must contact Licensing to approve the rooms before usage. LPA reviewed and inspected the Licensee's home and backyard for any health and safety hazards. The house is in good condition, with appropriate temperature and ventilation. The Licensee offered a good selection of age-appropriate toys and equipment. All cleaning supplies, poisons, and other chemicals were kept out of reach of children. The house has a fully charged fire extinguisher, smoke and carbon monoxide detectors, and a functional phone. The facility has a fully stocked first aid kit available for children. There were no pools, spas, or bodies of water on the site. The backyard is completely fenced, and outdoor play equipment is in good working order. Continued on page 2...

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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: SHUBAYEV, ALENA	FACILITY NUMBER: 384001641
	VISIT DATE: 10/06/2022

NARRATIVE

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No children's records were reviewed. The Licensee's Pediatric First Aid/CPR certification is current and will expire on 11/2023. The Licensee kept up with her immunizations, Mandated Reporter Training AB 1207, and has proper daycare liability insurance valid until through Westchester. The most recent fire & earthquake drill was held on October 5, 2022. LPA advised Licensee to document and maintain emergency drills appropriately.

All mandatory postings are observed (License/Parent's Rights poster/Emergency Disaster Plan and Earthquake Preparedness Checklist).

During the inspection, the following was discussed and provided to the Licensee

The Licensee was given information regarding Safe Sleep Regulations. Effective July 1, 2020, Licensees must have proof of completion of EMSA-certified lead poison training if applying for a change of location or capacity to an existing license.
The Licensee was reminded that as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.
The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website.
LPA reviewed AB 1207 with the Licensees. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.
LPA discussed care and supervision with the Licensee. Capacity options were reviewed, and the Licensee acknowledges that care cannot be provided over the capacity specified on the license.

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SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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: SHUBAYEV, ALENA	FACILITY NUMBER: 384001641
	VISIT DATE: 10/06/2022

NARRATIVE

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The 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: www.ada.gov/childqanda.htm.

The Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption or transfer their existing clearance or exemption prior to the initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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: SHUBAYEV, ALENA	FACILITY NUMBER: 384001641
	VISIT DATE: 10/06/2022

NARRATIVE

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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

No deficiencies were cited today under CCR, Title 22, Div. 12.

Today's report and site visit notice were provided to Elena Shubayev. LPA reminded the Licensee a site visit notification must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. For additional questions, the Licensee was advised to contact the CCLD office, Monday to Friday, 8:00 am - 5:00 pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brendon Van	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC809 (FAS) - (06/04)

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