434415608-5-14-2020-07-CC-MSMS-BPLPUY-20200514113820

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415608
Report Date: 05/14/2020
Date Signed: 05/14/2020 11:42:50 AM

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:	ROSHKO, INNA		FACILITY NUMBER:	434415608
ADMINISTRATOR:	ROSHKO, INNA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 272-1887
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94086
CAPACITY:	14	CENSUS: 0	DATE:	05/14/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Inna Roshko		TIME COMPLETED:	10:45 AM

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) Mel Matos conducted an announced prelicensing tele-inspection via video conference call (FaceTime) with Inna Roshko, Applicant. The purpose of today's tele-inspection: address Application for a Large Family Child Care Home license (change of location) that the Applicant submitted to the Department on April 27, 2020. The Applicant is currently licensed at 1139 Prescott Ave, Sunnyvale, CA 94089 (#434413955). Application/Record Review: No other adults or children were present in the home during today's tele-inspection. The adults that reside in the home: Applicant and her adult son (Aleksey Berezuk). The Applicant does not have any minor children. Days and hours of operation will be Monday to Friday from 8 AM to 6 PM. The Applicant is enrolled to renew her Preventative Health and Safety Child Care Training on July 18, 2020. The Applicant's CPR and First Aid certifications expired on 03/31/2020 and she is enrolled to renew her certifications on June 21, 2020. Proof of enrollment for both certifications is on file. Updated vaccinations and proof of completion of the Mandated Reporter Training for Child Care Workers (completed 04/27/2020) are on file. The Applicant rents the home and a copy of the signed Owner/Landlord Notification (LIC 9151) and Owner/Landlord Consent (LIC 9149) forms are on file. LPA observed a valid lease agreement verifying control of property during today's tele-inspection. All individuals subject to a criminal record review (Applicant & Applicant's son) have obtained a criminal record and child abuse index clearances prior to today's tele-inspection. A fire safety inspection request approval was received from the Sunnyvale Department of Public Safety on May 7, 2020. The Applicant agreed to give LPA a tour of the home (indoor/outdoor) via FaceTime during today's tele-inspection. Physical Plant tour: There is a working telephone in the home (cell #415-272-1887). The home is clean and orderly, with heating and ventilation for safety and comfort. All window blind cords are inaccessible to children. The are no stairs inside the home. There are wall heater units inside the home. The off limit areas inside the home are: Bedrooms #3 & #4, two bathrooms, barricaded fireplace unit (living room), and kitchen. Off limit area outside the home: detached 2 car garage. The off limit areas inside the home are inaccessible to children. The off limit area listed above are also listed on the Facility sketch submitted by the Applicant. There are safe and age appropriate toys, play equipment, and materials for the children in the home. The Applicant has a designated area in the home where a child(ren) can be isolated if exhibiting signs of illness. The home has working smoke/carbon monoxide detectors in the home (tested by the Applicant during today's tele-inspection).

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2020

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ROSHKO, INNA	FACILITY NUMBER: 434415608
	VISIT DATE: 05/14/2020

NARRATIVE

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Physical Plant tour (cont.): The Applicant has one fire extinguisher (2A10BC) in the home that is fully charged. The Applicant does not have any firearms or pets in the home. All cleaning compounds and medications are adequately stored (high cabinets) and inaccessible to the children. There are no poisons inside the home. The Applicant states that he does not have any baby walkers in the home. The Applicant understands that baby walkers are not allowed in the home. The Applicant states that he does not have any baby bouncers, jumpers, saucer chairs, and trampolines in the home. The Applicant understands that inclined sleepers are not allowed in the home. The Applicant states that neither he or his partner smoke and he understands that smoking is prohibited in the home. The Applicant has a first aid kit in the home, which also has a thermometer and sufficient emergency supplies.

Kitchen tour: The refrigerator and freezer in the home is clean. There are no sharp utensils, lighter/matches, or open bottles of alcohol accessible to children. All cabinet and drawers in the kitchen are inaccessible to children. The Applicant understands that any food/drink which is brought by parent(s) of day care child(ren) must be properly labeled with the child(ren) name and properly stored or refrigerated.

Bathroom tour (two): The bathroom toilets and faucets are clean, safe, and operable. The bathtub and shower is free of any hazards. All shampoos, soap, medication, mouthwash, perfumes, razors, cleaning products, air fresheners, and nail polish/remover are inaccessible to the children via locked bathroom vanity and medicine cabinet.

Outdoor tour: The backyard area of the home is safe and secure for the children. The backyard area is adequately fenced and there are no bodies of water. LPA reminded the Applicant that the children must be supervised at all times while outdoors.

Document/Regulation Review: A Family Child Care Home packet with updated Licensing forms was mailed to the Applicant prior to today's tele-inspection and the Applicant acknowledged receipt of the packet. Documents from the packet, including but not limited to the following were discussed and reviewed with the Applicant: 1) Child Care Facility Roster (LIC 9140) must be complete and current at all times, 2) Fire/disaster drills must be practiced at least once every 6 months and documented on the fire/disaster drill log provided to the Applicant, 3) Posting requirements - Parent's Rights (PUB 394), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), and Facility License, 4) Staffing & Ratio - capacity/ratio limitations handout, 5) Safe Sleep Awareness (PIN 19-02-CCP), 6) Lead Flyer Requirement (PIN 20-01-CCP), and 7) Forms and Records to keep in your Family Child Care Home (LIC 311D).

Forms of discipline used by Applicant: talking to the children. The Applicant understands that children's personal rights should not be violated; including no corporal punishment, supervision of children, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed with the Applicant during today's tele-inspection.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2020

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ROSHKO, INNA	FACILITY NUMBER: 434415608
	VISIT DATE: 05/14/2020

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed with the Applicant during today's tele-inspection. 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. The Applicant states that he does not administer any medication to the day care children at this time.

Notification requirements/civil penalty: LPA discussed the requirements of AB 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant and advised him of the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected. LPA reminded the Applicant 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.

The Applicant was informed that due to the current COVID-19 pandemic and "Shelter In Place" Order, today's report (Facility Evaluation Report - LIC 809) will be emailed to the Applicant (email: innaroshk@gmail.com) with "Read Receipt" notification. The Applicant understands that his response to the email is considered an acknowledgement of "receipt" of today's report.

LPA conducted an exit interview and advised the Applicant that a 90 day "provisional" large Family Child Care Home license will be approved upon completion of the following:

1) Acknowledgement of "receipt" of today's report has been received by LPA Matos

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2020

LIC809 (FAS) - (06/04)

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