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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415154
Report Date: 03/06/2020
Date Signed: 03/06/2020 05:24:09 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: 10DATE:
03/06/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Liudmila DobrovolskayaTIME COMPLETED:
05:25 PM
NARRATIVE
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LPA Janet Tse met with licensee Liudmila Dobrovolskaya for a required annual inspection. At 2:35pm, LPA arrived at the facility. LPA knocked on the door and rang the door bell several times;but nobody answered the door. LPA contacted Licensee by phone and was informed that she was not home; but she will instruct her assistant to let LPA in the home. LPA waited for about 10 minutes before the assistant (YK) answered the door. When LPA entered the home, LPA observed ten children with Licensee's assistant (YK) alone. Licensee returned home with her daughter (SU) at 2:55pm. Another assistant (VK) arrived at 3:20pm. Licensee is the only adult living in the home. Days and hours of operation are Monday to Friday, 8:00am to 6:00pm.

LPA toured the indoor and outdoor of the home. LPA observed a blocked fireplace in the home. Off limits indoor: master bedroom, master bathroom, bedroom #1, bedroom #3, kitchen, dining room, and the garage. Licensee stated there is no firearms/weapons in the home. There are no bodies of water. Sharp objects, medicines, poisons and cleaning supplies are inaccessible to the children. Backyard is fenced. LPA reminded licensee that she can only have 14 children according to her license.

Fire extinguisher was size 2A10BC and filled. Smoke detector and carbon monoxide detector were operable. Home was clean and orderly with heating and ventilation for safety and comfort. LPA observed sufficient materials, toys, and play equipment for the day care children. Telephone is in working order. Children were supervised on the visit and LPA went over substitute options. LPA also discussed if licensee transports children, they are never to be left in parked vehicles and car seat laws are to be followed.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 03/03/2020 was reviewed; and it indicates that all Facility staff or other individuals who require caregiver background clearances have received criminal record and child abuse index clearances or exemptions.

LPA was provided a copy of the current roster of the children. LPA reviewed 11 children's files. LPA observed that in each child’s record has a copy of the emergency information card that contains all of
Facility Evaluation Report dated 03/06/2020 to be continued on next page: - Page 1 of 2 -
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2020
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DOBROVOLSKAYA, LIUDMILA
FACILITY NUMBER: 434415154
VISIT DATE: 03/06/2020
NARRATIVE
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Facility Evaluation Report dated 03/06/2020 to be continued from previous page:
the information specified by regulation. LPA observed that the assistant (YK), whose Pediatric CPR/1st Aid certification expired in August 2019, was alone with the children when LPA arrived at the home. Licensee's Pediatric CPR/1st Aid certification expires on 03/18/2020.

Licensee was given the current forms for childcare. Website to download forms, review regulations and to look for resources: http://www.ccld.ca.gov. Periodic information releases accessible by signing up at: www.myccl.ca.gov.

LPA discussed the immediate civil penalties for Zero Tolerance of $500, and an ongoing $100 per day per violation continues until the violation(s) is corrected. LPA also discussed the Healthy Beverage Act. AB792 Immunization Requirements was discussed. LPA observed the required immunization records for Licensee and her assistants were in file.

Effect of Lead Exposure handout dated 1/20/19 given during today’s inspection. Licensee understands that per Assembly Bill (AB 2370), written information regarding lead exposure needs to be given out to enrolling and re-enrolling parents or guardians. LPA reviewed infants safe sleep policies with Licensee and provided "A Child Care Provider's Guide to Safe Sleep.” More information can be found at https://cdss.ca.gov/inforesources/Child-Care-Licensing. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care. The Mandated Reporter AB1207 Compliant Child Care Training was also discussed. Website to complete training: https://mandatedreporterca.com. A link to the alternate trainers approved to provide training:
https://www.cdss.ca.gov/Portals/9/CCLD/CCP%20Documents/Approved%20Mandated%20Reporter%20Trainings.pdf Licensee's and her assistants' primary language is Russian and are not proficient in the English language. Licensees and her assistants are currently exempt from the training.

LPA discussed the requirements of AB633 to Licensee/director and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Licensee understands the requirements. Upon receipt, Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

Deficiencies were cited. Notice of site visit was issued and must be posted with type A deficiency for 30 days. Licensee's daughter (SU) translated for Licensee during today's inspection.
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SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2020
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DOBROVOLSKAYA, LIUDMILA
FACILITY NUMBER: 434415154
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2020
Section Cited

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Staffing Ratio and Capacity. If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).
This requirement was not met as evidenced by:
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At LPA's arrival, LPA observed ten children with Licensee's assistant (YK) alone in the home.
This poses an immediate risk to the Health, Safety, or Personal Rights of children in care.
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AB633 Parent Notification is required.
This page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements

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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2020
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: DOBROVOLSKAYA, LIUDMILA
FACILITY NUMBER: 434415154
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/06/2020
Section Cited

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Personnel Requirements. ...The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
This requirement was not met as evidenced by:
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LPA observed that the assistant (YK), whose Pediatric CPR/1st Aid certification expired in August 2019, was alone with the children when LPA arrived at the home.
This poses a potential risk to the Health, Safety, or Personal Rights of 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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Janet TseTELEPHONE: (408) 334-8547
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4