414004257-11-14-2019-05-CC-JSAI-BHWTZ3-20191114140939

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004257
Report Date: 11/14/2019
Date Signed: 11/14/2019 02:09:52 PM

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:	CHELNOKOVA, LUDMILA		FACILITY NUMBER:	414004257
ADMINISTRATOR:	CHELNOKOVA, LUDMILA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 516-4451
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	14	CENSUS: 11	DATE:	11/14/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Chelnokova Ludmila		TIME COMPLETED:	02:20 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) Jyoti Saini conducted an Annual Inspection, which included a tour of the home and back yard, and a review of the required day-care forms with the licensee today. Present in the home were 11 children with licensee and one helper, Ekaterina Orlova. Facility is operating in ratio on this day. Day-care operates M-F, 8:00 AM - 6:00 PM. The Day care area is family room, Bedroom #1 and Bathroom #1 and backyard Off limit areas : Garage, laundry room, and entire upper level( except shared main entrance). Off limits areas are kept inaccessible to the children. LPA observed the following: The day-care area is clean, orderly, and equipped with age appropriate toys and equipment for the children. No baby walkers, bouncers etc. allowed to be used during day-care hours. Home has proper lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher. Licensee states there are no bodies of water on the property. There are no detergents, or cleaning products accessible to day-care children. Poisons are locked. Licensee states there are no guns or weapons of any kind in the home. The yard is fenced off. Emergency drills are conducted at least once every six months and properly logged. Per log, last drill was conducted on 09/09/19 @ 9:35AM. Licensee provides Breakfast, Lunch and two snacks. Discipline policy is time out. All required postings are properly posted. There is no fire place in the day care area. Children’s roster was reviewed and is complete and up-to-date. Copy of the roster is obtained during the visit. .8 children files and two personnel files were reviewed for required licensing documents. All children files are complete and up to date.Records indicates that all adults working or living in the home who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee's first aid/CPR certification expires in 11/20. Licensee has day-care insurance through DC insurance services,INC. Continuation on next page...

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019

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 2

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: CHELNOKOVA, LUDMILA	FACILITY NUMBER: 414004257
	VISIT DATE: 11/14/2019

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
26
27
28
29
30
31
32

LPA discussed mandated reporter training that is required for adults working with children in the home. Licensees and her helper's primary language is Russian so both are exempted to take mandated reporter training.

During Inspection

*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

*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption. pursuant to Health and Safety code 1596.7995 and 1597.662.

*Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.

*Licensee was given information regarding ‘Safe Sleep’ practices.

No deficiencies were issued today under Title 22 Division 12 of the Ca. Code of Regulations.

This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.

Licensee was advised any additional questions to call Office, M-F, 8:00AM-5;00PM, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019

LIC809 (FAS) - (06/04)

Page: 2 of 2