414003076-9-19-2023-05-CC-LGOZ-CVU242-20230919170314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414003076
Report Date: 09/19/2023
Date Signed: 09/19/2023 05:03:25 PM

Document Has Been Signed on 09/19/2023 05:03 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	MYZHALA, OKSANA		FACILITY NUMBER:	414003076
ADMINISTRATOR:	MYZHALA, OKSANA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 255-2419
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94402
CAPACITY:	14	CENSUS: 9	DATE:	09/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Oksana Myzhala		TIME COMPLETED:	05:10 PM

NARRATIVE

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On 9/19/2023 at 2:30PM., Licensing Program Analysts (LPA), Luis J. Gomez met with Licensee, Oksana Myzhala. Purpose of the inspection was explained and was for an Unannounced; Annual Random. Present was the licensee and two helpers caring for 9 children. Adults have criminal record clearances on file. Licensee's home is three bedroom, three bathroom, two level townhouse. Days and hours of operation are Monday- Friday, 8:00- 5:30pm. Day-care area are: First Floor: Living Room (Playroom); Dining Room (Napping Area); Bathroom #1 and Backyard Area. Off-limit area are: First Floor: Garage; Kitchen; Entire Second Floor: Bedroom #1; Bedroom #2; Bedroom #3, Bathroom #2; and Bathroom #3. LPA inspected home with licensee for health and safety hazards.

At 2:35PM., the following was observed: Facility was clean, with age-appropriate playthings available for the children. Floors/ground was clear of obstructions or potential hazards. Accessible furniture, blocks, and books inspected were in good repair. Cubbies are in entry way for storage of belongings. Child sized tables and chairs are available for seated activities. For napping services, LPA observed several napping mats and play pen (with tight-fitting sheet). Staircase have been made inaccessible with child safety gate installed. Fireplace has been properly barricaded. Bathroom #1 was clean with supplies for hand washing.

At 2:40PM., LPA observed accessible detergent in bathroom #1. Licensee removed item during inspection. Advisory Note: Technical Violation (LIC9102TV) was issued.

Facility was the proper temperature, with adequate ventilation and lighting. Home had functioning telephone service; smoke detector, carbon monoxide detector; and fire extinguisher: 3A:40:BC. (REFER TO 809C, FOR CONT)

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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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Document Has Been Signed on 09/19/2023 05:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MYZHALA, OKSANA	FACILITY NUMBER: 414003076
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102416.5(a)

Staffing Ratio and Capacity

(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	At 3:20PM., Based on record review, interviews and observations, LPA confirmed licensee is operating over capacity with 5 infant-age children in care. This poses a potential health and safety risk to children in care.
	POC Due Date: 09/20/2023
	Plan of Correction
1 2 3 4	Licensee will reduce facility's total enrolled capacity to required 4 infants by the due date: 9/20/2023. Proof of correction (Children's Roster) will be submitted to the department via email. Authoirzed Representives must sign the LIC9224, Notice of A type deficiency.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MYZHALA, OKSANA	FACILITY NUMBER: 414003076
	VISIT DATE: 09/19/2023

NARRATIVE

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(Page 2)
LPA reviewed the back yard area. Area was completely enclosed with playthings inspected in good repair. LPA observed shaded rest area available. Facility does not have any pools, fishponds, or other bodies of water.

At 3:15PM, LPA reviewed facility records including the staff and children’s files.

Children’s files were reviewed and included the: Notification of Parent's Rights (LIC995); Identification of Emergency Information (LIC702); and Consent for Medical Treatment (LIC627).

LPA reminded licensee to ensure children immunization records are stored in facility files.

At 3:20PM., Based on record review, interviews and observations, LPA confirmed licensee is operating over capacity with 5 infant-age children in care.

LPA reminded licensee to ensure each 15 minutes review for napping infants in care is properly documented. Advisory Note: Technical Violation (LIC9102TV) was issued.

Staff files were reviewed and included the: Employee Rights (LIC9052); Proof of Required Immunization; and Criminal Record Statement (LIC508).

Licensee's Cardiopulmonary Resuscitation (CPR)/ First Aid certification was current, expiring: 5/2025.

Licensee’s ‘Mandated Reporter Training’ Certification’(AB1207) was current, expiring: 2/6/2025.

Licensee is conducting emergency disaster drills every six months, with last drill done on: 7/5/2023.

Required forms are posted in entry way, including the Childcare License; Notification of Parent’s Rights (PUB379); Emergency Disaster Plan (LIC610A). Per licensee, isolation of an ill children is in hallway.

Per licensee, she provides food services for children in care. LPA advised licensee to ensure all children’s food containers brought by families are be labeled. Per licensee, home does not have any firearms.

Licensee was reminded that all adults 18 years and over living in the home, person who provides care and supervision to children, and staff who have contact with children, including employee and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain criminal clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated. (REFER TO 809C, FOR CONT.)

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MYZHALA, OKSANA	FACILITY NUMBER: 414003076
	VISIT DATE: 09/19/2023

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(Page 3)
LPA discussed the safe sleep regulations with licensee and discussed Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee was informed of the www.mychildcareplan.org site is a consumer education website that helps families obtain child care by connecting to child care providers and resources and referral agencies (R&R) throughout California.

Incidental Medical Services (IMS) policy was discussed. For IMS information, see PIN 20-02-CCP. When an IMS is provided, a plan for 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- 0382 (TTY) and link to publications: Commonly asked questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

To improve the quality and value of the new inspection process, a survey may 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 tool, please send them 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/inforesource/community-care-licensing/inspection-process.

Based on today's inspection, deficiencies were observed in areas evaluated according to California Title 22, Div. 12 Chap. 3 Health and Safety Code of Regulations and cited on 809D. LPA conducted exit interview with licensee, Oksana Myzhala, Licensee’s signature of this form acknowledges receipt of these documents.

During exit interview, licensee, Oksana Myzhala confirmed that there are no registered sex offenders living in the facility, and LPA completed the RSO profile. Notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis Gomez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC809 (FAS) - (06/04)

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