434415451-8-15-2022-07-CC-PHEZ-CHBQZC-20220815123631

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415451
Report Date: 08/15/2022
Date Signed: 08/15/2022 12:36:42 PM

Document Has Been Signed on 08/15/2022 12:36 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	AMBARTSUMOVA, KARINA		FACILITY NUMBER:	434415451
ADMINISTRATOR:	KARINA AMBARTSUMOVA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(818) 306-7090
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY:	14	CENSUS: 7	DATE:	08/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Karina Ambarsumova		TIME COMPLETED:	01:15 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), Pete Hernandez met with Licensee, Karina Ambartsumova, and conducted an unannounced Required 1 Year inspection. Also present in the home was Licensee's minor son., Licensee and her husband are the only two adults that reside in the home with their minor son.. Days and hours of operation are Monday thru Friday from 8:00 AM to 6:00 PM. ( Visiting adult Daughter Victoria Ambartsumova served as the translator from Russian to English.) Also present were 2 Assistants: Margarita Kochengina and Elina Martirosova. LPAs toured the home both indoor and outdoor. Off limit areas in the home: Kitchen, two bedrooms, master bedroom and bathroom, and the garage. Off limit areas outside the home: left side of the backyard and back garden area. patio. LPA noted that all off limit areas have gated barricades. LPA observed: fully charge 2A10BC fire extinguisher, functioning smoke and carbon monoxide detector and fire pull stations, and fenced backyard. The Licensee has a working telephone in the home. LPAs observed sufficient materials, toys, and play equipment for the day care children. The home is orderly, and safe for the day care children. LPA didn't observed any bodies of water. Licensee understands that all pools, spas, hot tubs, fish ponds, or similar bodies of water shall be covered or fenced as specified in title 22 regulations to be inaccessible to children. The Licensee stated that there are no firearms or dangerous weapons in the home. LPA observed current roster. Also observed was the fire / emergency drill log that is updated every 6 months; last entry was 3/10/22.. All required postings are easily observed in the front entry room. LPA reminded the Licensee that all cleaners must be stored out of reach of the children at all times. All detergents, cleaning compounds, other similar items and poisons are in the garage and are inaccessible to children. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 8/15/2022:

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: AMBARTSUMOVA, KARINA	FACILITY NUMBER: 434415451
	VISIT DATE: 08/15/2022

NARRATIVE

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LPA reviewed the files of 7 enrolled children and all the files have all of the required documentation and immunization's. LPA also reviewed the files of the 2 assistants. One Assistant was missing her measles and TB documentation from her file.

Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was also 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

A review of staff records today indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances. LPA also reminded 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. Licensee understands that she must be present in the home at least 80 percent of the hours the day care is in operation and ensure that the children are supervised at all times. The Licensee understands her capacity options. The Licensee states that she does not transport children and understands that children cannot be left in parked vehicles unattended at any time. Licensee understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick child, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.
LPA informed Licensee that Licensing forms and Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov
REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #3 - REPORT DATED 8/15/2022

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: AMBARTSUMOVA, KARINA	FACILITY NUMBER: 434415451
	VISIT DATE: 08/15/2022

NARRATIVE

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Licensee has a current Mandated Reporter Certificate. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed at www.mandatedreporterca.com.

Website for resource information: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPA discussed the LIC 9227 as it relates to infants and printed out a copy for her.

Licensee has a current CPR and First Aid card that expire on 6/1/2023.

LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov

Type A language: Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. Please see 809D. An exit interview was conducted were reviewed and developed with the licensee. A copy of this report and appeals rights were discussed and left with the Licensee, AMBARTSUMOVA, KARINA , whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/15/2022 12:36 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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: AMBARTSUMOVA, KARINA	FACILITY NUMBER: 434415451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Per LPA’s review, Staff 1 has been working at the family day care but does not have documentation that Staff 1 is immunized against Measles, Pertussis and Influenza. This poses a potential risk to the health and safety of children in care.
	POC Due Date: 09/15/2022
	Plan of Correction
1 2 3 4	BY POC DUE DATE: Licensee will obtain documentation of the required Measles, and TB immunizations for Staff 1. A copy of the documentation will be sent to the Licensing Office as proof of correction

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: Gladys Kuizon	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022

LIC809 (FAS) - (06/04)

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