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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415451
Report Date: 08/23/2023
Date Signed: 08/23/2023 12:04:28 PM


Document Has Been Signed on 08/23/2023 12:04 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, KARINAFACILITY NUMBER:
434415451
ADMINISTRATOR:KARINA AMBARTSUMOVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 306-7090
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:14CENSUS: 10DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Karina AmbartsumovaTIME COMPLETED:
12:30 PM
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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 her Assistant 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. Also present were 1 Assistants: Margarita Kochengina. LPA observed 2 infants and 8 preschoolers. .
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. LPA 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 3/4/23. 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.

LPA reviewed the files of 5 enrolled children, all the files have all of the required documentation and immunizations. LPA reviewed 1 Staff files and all the required documentation was in the files.
Licensee talks to the children and uses redirection as forms of discipline. Licensee understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.
REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 8/23/2023)
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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 3


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: 08/23/2023
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 8/23/2023):

LPA informed the Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record 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.
Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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.


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.

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 CARE tools, please send email inquiries 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/inforesources/community-care-licensing/inspection-process.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: AMBARTSUMOVA, KARINA
FACILITY NUMBER: 434415451
VISIT DATE: 08/23/2023
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LPA went over Regulation 102425(j) and (j)(2)(D) regarding infant care and LIC 9227 (Infant Sleeping Plan). LPA Provided a copy. The provider shall supervise infants while they are sleeping.

Licensee has a current CPR and First Aid card that expires 6/1/25.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://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 MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California

During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA observed all required postings on the wall in the children's playroom.



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.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. Exit interview conducted and report was reviewed with the License Karina Ambartsumova.

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 KuizonTELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
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