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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415154
Report Date: 08/09/2019
Date Signed: 08/09/2019 02:04:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:DOBROVOLSKAYA, LIUDMILAFACILITY NUMBER:
434415154
ADMINISTRATOR:DOBROVOLSKAYA, LIUDMILAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 893-0830
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:14CENSUS: 9DATE:
08/09/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Svetlana UmanskyyTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Peter Tinkelenberg and Licensing Program Manager Diana Stephenson met with Licensee's daughter, Svetlana Umanskyy. Licensee Liudmila Dedkovskaya was present during the entire inspection. Svetlana acted for the Licensee during this inspection. We introduced ourselves and Svetlana invited us to enter the home. LPA observed Licensee, Svetlana, and two assistants (Valeriya Kuzmenko and Yelena Korenkova) initially caring for two children. By 9:10 AM there were nine children present, one of which was an infant. Days and hours of operation are Monday - Friday from 8:00 AM to 6:00 PM.

LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. Children’s toys, play equipment and materials are safe and age appropriate. The home is kept clean and orderly, with heating and ventilation for the safety and comfort of the children. LPA observed a fireplace that was screened. There are no stairs inside the home. Licensee states there are no baby walkers or bouncers in the home. Off limit areas inside the home are: four bedrooms, the study, laundry room, and kitchen, which is gated. LPA observed a fully charged 2A10BC fire extinguisher, a working smoke alarm with carbon monoxide detector. The Licensee states that she does not have any firearms in the home. Poisons, detergents, and medicines are inaccessible to children. Outdoor play areas are fenced. The backyard play area is padded where a plastic slide is located and artificial turf where children can play with the riding equipment.

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 04/04/2019. The Licensee completed the required Mandated Reporter training on 03/17/2018. Licensee's CPR and First Aid certifications are current and expire on 03/18/2020. Licensee received her Health Practices certification on 01/15/2017. Licensee was immunized against measles and pertussis on 03/19/2018. Assistant Svetlana Umanskyy declined flu vaccination but has been vaccinated against pertussis and measles, and is TB cleared. Svetlana has completed her Mandated Reporter training
Continued on page 2 dated August 9, 2019
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DOBROVOLSKAYA, LIUDMILA
FACILITY NUMBER: 434415154
VISIT DATE: 08/09/2019
NARRATIVE
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Continued from page 1 dated August 9, 2019
and completed form LIC 9108. Assistants A-1 and A-2 are missing immunization records, have TB clearance but have declined flu vaccine. A-1 has completed Mandated Reporter training and the LIC 9108. A-2 is a new employee so she will have up to 90 days to complete her Mandated Reporter training. She did sign LIC 9108. Licensee, Svetlana, and the two assistants have fingerprint clearance. Licensee employs a music and art teacher to provide cultural activities. They have fingerprint clearance. Teacher 1 (Oksana Kostouros)) has not completed Mandated Reporter Training. Teacher 2 (Saltanat Ulanbek) must also complete Mandated Reporter training. In addition, T-2 needs vaccination against pertussis. T-2 declined flu vaccination. T-2 must also need TB clearance.

LPA reviewed nine children's files. All files have completed the following forms: Identification and Emergency Information, Consent for Medical Treatment, and Affidavit Regarding Liability Insurance. Child C-8 is missing the Notification of Parents' Rights. The following children do not have the Parent Notification of Additional Children in Care updated: C-1, C-3, C-5, and C-9. Child C-2 is missing MMR.

A review of staff records on 08/08/2019 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded the Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time with a qualified assistant present. The Licensee understands that she must comply with the capacity and ratio requirements of the small Family Child Care Home License whenever there is only one qualified adult present in the home. The Licensee states that she does not transport children. The Licensee does not administer any medication to the day care children at this time. Incidental Medical Services (IMS) Continued on page 3 dated August 9, 2019
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DOBROVOLSKAYA, LIUDMILA
FACILITY NUMBER: 434415154
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2019
Section Cited
CCR
102418(g)(1)
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102418(g)(1) Immunization. The licensee shall document … and shall maintain such documentation for as long as the child is enrolled. This requirement includes updating each child's PM 286 (6/95) …

This requirement was not met as evidenced by:
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By August 23, 2019, Licensee will provide copies of updated PM 286 with complete MMR for C-2. Licensee can send the copies to LPA by email, fax, or mail carrier.
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Based on inspection of children's files, Licensee failed to update the immunization records of C-2, C-3, C-5, and C-7, which poses a potential risk to the health and safety to the children in care.
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Type B
08/23/2019
Section Cited
CCR
102421(a&b)
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102421(a & b) Child's Records. The licensee shall maintain, in each child's record, the signed and dated notice FCCH Notification of Parents’ Rights (LIC 995B) form required in Section 102419(d).

This requirement was not met as evidenced by:
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By August 2, 2019, Licensee will provide a copy of the completed Notification of Parents' Rights for C-8. Licensee can provide a copy by email, fax, or mail carrier.
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Based on inspection of children's files, Licensee failed to include a completed Notification of Parent's Rights for C-8, which posed a potential risk to the health and safety to the 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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019
LIC809 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DOBROVOLSKAYA, LIUDMILA
FACILITY NUMBER: 434415154
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2019
Section Cited
HSC
1597.622(a)(1)
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H & S 1597.622(a)(1) Employees or volunteers at family day care home; immunization requirements; records; exemptions. … a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles.
This requirement was not met as evidenced by:
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By August 23, 2019, Licensee will provide copies of immunization agaist the pertussis, and measles, and TB clearance for T-1. Licensee may send the copies by email, fax, or mail carrier.
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Based on inspection of personnel files, Licensee failed to provide documentation that I-2 has been immunized against the flu, pertussis, and measles, and TB clearance, which poses a potential rish to the health and safety of the 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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019
LIC809 (FAS) - (06/04)
Page: 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DOBROVOLSKAYA, LIUDMILA
FACILITY NUMBER: 434415154
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2019
Section Cited
CCR
102416.5(h)(2)
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102416.5(h)(2) Staffing Ratio and Capacity: For a Large Family Child Care Home that meets the criteria to care for up to two additional children, the licensee shall maintain proof of parent notification as specified in Section 1597.465(c) of the Health and Safety Code.
This requirement was not met as evidenced by:
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By August 23, 2019, Licensee will provide copies of completed Parent Notification of Aditional Children in Care for C-1, C-3, C-5, and C-9. Copies will be sent to LPA by email, fax, or mail carrier.
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Based on inspection of children's files, Licensee failed to provide updated Parrent Notification of Additional Children in Care for C1, C-3, C-5, and C-9, which poses a potential risk to the health and safety of childrenin care.
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Type B
09/23/2019
Section Cited
HSC
1596.8662
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HSC - 1596.8662 Training for Mandated Reporter who is licensed day care provider. On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training ...
This requirement was not met as evidenced by:
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By September 23, 2019 Licensee will provide a copy of the Mandated Reporter certificate for T-1. Copy may be sent to LPA by email, fax, or mail carrier.
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Based on inspection of personnel files, Licensee failed to provide the Mandated Reporter certificate for I-1, which poses a potential risk to the health and safety to the 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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DOBROVOLSKAYA, LIUDMILA
FACILITY NUMBER: 434415154
VISIT DATE: 08/09/2019
NARRATIVE
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Continued from page 2 dated August 9, 2019
policy was discussed. For IMS regulations Licensee was instructed to Google15FCCH-01.When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regardingADA 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

The following websites for provider information were presented: http://www.cdss.ca.gov/inforesources/Community-Care-Licensing/Policy/Provider-Information-Notices

To subscribe to Quarterly Update: http://www.cdss.ca.gov/inforesources/Community-Care-Licensing/subscribe

LPA explained safe sleep for infants. www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

Five Type B deficiencies were cited during today's inspection. Appeal Rights provided and exit interview conducted.


A NOTICE OF SITE VISIT WAS PROVIDED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Peter TinkelenbergTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019
LIC809 (FAS) - (06/04)
Page: 3 of 6