434416335-2-16-2022-07-CC-PHEZ-CBPQ47-20220216104953

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416335
Report Date: 02/16/2022
Date Signed: 02/16/2022 10:50:40 AM

Document Has Been Signed on 02/16/2022 10:50 AM - It Cannot Be Edited

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:	TSYMBALIUK, ALONA		FACILITY NUMBER:	434416335
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 5	DATE:	02/16/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Alona Tsymbaliuk		TIME COMPLETED:	11:02 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	On 2/16/2022 at 8:00AM: Licensing Program Analyst (LPA) Pete Hernandez conducted an announced Pre-licensing inspection for a Large Family Child Care Home. Licensee moved to this new home after relocating late last year and wishes to apply for her Large Family Child Care Home. LPA met with Applicant, Alona Tsymbaliuk and explained the purpose of today's inspection and to address the licensees request for a Pre licensing for a Large Family Home. Present in the home was her husband . Licensee lives in the home with her husband: Sergii Tsymbaliuk. Licensee also lives with her two minor sons. Licensee rents the home. Licensee will provide an affidavit to parents that she does not carry insurance. The hours of operation are Monday through Friday 8:00AM to 6:00PM. LPA toured the indoor and outdoor areas of the home a second time during today's inspection: In Use Areas: Living Room, Activity Room, downstairs bathroom, and downstairs bedroom. Off Limit Areas: Master bedroom and master bathroom, kitchen, entire upstairs and Garage. Outdoors: Back yard is fenced and available for the children to use. (Both side yards are fenced off, barricaded and off limits to the children.) Fire drills are to be conducted are every 6 months. Licensee will maintain a current children's' roster. 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 observed a fully charged 3A40BC fire extinguisher in the kitchen. There are working hard wired smoke alarms and plug in carbon monoxide detectors. The home has hard wired fire pull stations in the home. LPA did not observe any bodies of water on the immediate property. The 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. Applicant states that there are no weapons or firearms in the home. All detergents, cleaning compounds, other similar items and poisons are out of reach, and are inaccessible to children. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 2/16/2022:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

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

FACILITY NAME: TSYMBALIUK, ALONA	FACILITY NUMBER: 434416335
	VISIT DATE: 02/16/2022

NARRATIVE

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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 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 or exemptions. 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 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

LPA reviewed some of the the pre licensing packet and requirements staff and children's files. LPA reviewed a sample of both and the Licensee's files were complete and organized.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #3 - REPORT DATED 2/16/2022:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

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

FACILITY NAME: TSYMBALIUK, ALONA	FACILITY NUMBER: 434416335
	VISIT DATE: 02/16/2022

NARRATIVE

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Licensee does have current Mandated Reporter Certificate and will expire on 2/1/2024. 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 the Licensee. 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.
Licensee has a current CPR and First Aid card that expires 05/8/23.
Licensee provided a copy of the children's facility roster.
Website for resource information: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

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

Licensee has applied for a Large Family Child Care Home and understands that the license is to be reviewed by Management prior to licensing approval.

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 NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted, and Plan of Corrections were reviewed and developed with the Licensee. A copy of this report and appeals rights were discussed and left with the Licensee, Alona Tsymbaliuk , 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.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

LIC809 (FAS) - (06/04)

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