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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483007592
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:58:47 PM


Document Has Been Signed on 09/27/2024 12:58 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:VAEZINIA, VICTORIA FAMILY CHILD CARE HOMEFACILITY NUMBER:
483007592
ADMINISTRATOR:VAEZINIA, VICTORIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 452-8888
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:14CENSUS: 9DATE:
09/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lyubov Mailova - Facility RepresentativeTIME COMPLETED:
01:15 PM
NARRATIVE
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During the course of a complaint investigation visit, Licensing Program Analyst (LPA), Melchisedeck Augustin made a Case Management visit and met the Facility Representative, Lyubov Mailova, to deliver a type B citation.

During today's visit, LPA counted nine children in care with the Facility Representative and two staff (S1 & S2), and LPA noted that the Licensee (LS) was not present. According to the Facility Representative, the facility's operating hours were 7:30am - 5:30pm or 6:00pm and the Representative confirmed that LS had been absent from the facility due to personal reasons since about 7:00am. LPA consulted with Facility Representative on California Code of Regulations (CCR) 102417(a) which indicated that the licensee shall be present in the home and shall ensure that children in care are supervised at all times, and when circumstances require the Licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. Furthermore, LPA reminded Facility Representative of the requirement and informed if LS's absence exceeded 20 % of the operating hours per day, then LS was required to close the facility for that day.

At 11:19am, LPA reviewed thirteen children's (C1-C13) records which revealed C2 was missing the second page of Individual Infant Sleeping Plan (LIC 9227) and Consent for Emergency Medical Treatment (LIC 627) was not signed, C7-C8 were missing Parents Rights (LIC 995) and Identification and Emergency Information (LIC 700); and C13's California Department of Public Health (CDPH) form 286 was incomplete.

Exit interview conducted and report was reviewed with the Facility Representative, Lyubov Mailova. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. The following violation(s) of the California Code of Regulations, Title 22; Division 12, was observed during today’s visit. See LIC 809-D. Appeal Rights were provided.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
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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Document Has Been Signed on 09/27/2024 12:58 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: VAEZINIA, VICTORIA FAMILY CHILD CARE HOME
FACILITY NUMBER: 483007592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2024
Section Cited
CCR
102421(b)

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The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7).

This requirement was not met as evidenced by: Based on LPA's review of thirteen children's records which revealed C7-C8 were missing LIC 700. This posed a potential health, safety
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Facility Representative said she provide and obtain completed LIC 700 to C7-C8's parents, and Representative intends to submit evidence of the completed LIC 700 forms as well as evidence of the second page of LIC 9227 for C2, and completion of C13's CDPH 286.
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and/or personal rights risk to children in care
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Email: melchisedeck.augustin@dss.ca.gov
public inbox: cclrpregionalofficegeneral@dss.ca.gov
Fax: 707-588-5099

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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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
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