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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503911280
Report Date: 06/04/2020
Date Signed: 06/04/2020 12:14:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:GLUKHOVSKIY, KIMBERLY FAMILY CHILD CAREFACILITY NUMBER:
503911280
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
06/04/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Kimberly GlukhovskiyTIME COMPLETED:
12:45 PM
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Prior to today's inspection, LPA telephoned call applicant and conducted the COVID-19 Emergency Response Tele-Inspection Screening Process. On June 4, 2020, Licensing Program Analyst (LPA), Norma Lomeli met with Applicant, Kimberly Glukhovskiy for a pre-licensing inspection. Applicant, her husband and two minor children reside in the home. Background clearances are discussed and LIS 531 is signed indicating that the adults currently living in the home and/or providing care and supervision to children have a criminal record clearance.

Facility was inspected inside and outside as shown on the facility sketch and the following items were discussed:
  • This is a single story, three bedrooms and two bathrooms home and children will have access to the living room, kitchen, family/dining room, bedroom #1 and hallway bathroom. Off-limits rooms are made inaccessible by use of plastic door knob covers.
  • LPA observed children size furniture, safe toys, books and instructional materials for the children. Children will nap in bedroom #1 on mats. Infants will nap in play yards. Applicant understands she is to supervise children at all times.
  • Facility has 2A10BC fire extinguisher, smoke alarm, carbon monoxide alarm and first aid kit in place.
  • Applicant’s Pediatric CPR and First Aid certification was completed through Pediatric Plus with Emergency Medical Services Authority stickers (EMSA) and expires on April 30, 2022.
(Continued on LIC809-C):
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma LomeliTELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2020
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: GLUKHOVSKIY, KIMBERLY FAMILY CHILD CARE
FACILITY NUMBER: 503911280
VISIT DATE: 06/04/2020
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  • Knives are stored inside the knife block that is located on top of the refrigerator. Medications are stored inside the kitchen pantry that is made inaccessible by the use of a plastic door knob cover. Cleaning compounds are stored in the master bathroom.
  • Advised applicant fire drills are to be conducted once every 6 months and must be documented with date and time. A fire drill log was provided as an example.
  • Applicant is advised at least one staff member with current training in pediatric first aid and pediatric CPR is to be on site at all times children are present.
  • There are no bodies of water in the home or premises.
  • There are two dogs that will be kept indoors accessible to the day care children. Applicant is advised it is her responsibility to ensure the safety of children in care at all times from the pets.
  • Firearms are stored in accordance with Title 22 Regulations and ammunition is stored locked separate in accordance with Title 22 Regulations. Applicant is reminded that any advertising (of day-care) such as business cards, flyers/posters, and/or signs must include facility number as per Title 22 Regulation "Advertisements and License Number" 102359 (a).
  • Applicant is advised that smoking is prohibited on the premises of a family child care home as specified in Health and Safety Code Section 1596.795(a). Applicant states the home is smoke-free.
  • Applicant states she will not be transporting day care children. Applicant understands that she must have proper restraints and/or car seats for all the children under her care when transporting children.
  • Fenced backyard has a cemented and sodded area for the day care children. There is patio furniture, a play house, a Lifetime basketball hoop, balls and a empty wade pool. There is a shed where gardening tools are stored. The shed is made inaccessible by the use of a zip tie.
  • SB 792 immunizations verified and on file.
  • Applicant completed the Mandated Reporter Training on June 2, 2020.
  • LPA discussed safe sleep pending regulations and Safe Sleep Regulation Concepts were given to applicant.
(Continued on LIC809-C):
SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma LomeliTELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2020
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: GLUKHOVSKIY, KIMBERLY FAMILY CHILD CARE
FACILITY NUMBER: 503911280
VISIT DATE: 06/04/2020
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  • Incidental Medical Services (IMS) policy was discussed. 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.

Required postings, forms packet, which included Parent Notification Requirement and LIC9224 were provided and discussed in detail. Applicant is advised that she may access CCLD website at www.ccld.ca.gov for additional forms and licensing updates. She is also reminded that it is her responsibility to read the regulations periodically. Applicant states she will operate her day care Monday through Friday from 7:00 AM to 5:00 PM and as arranged. No overnight care will be provided.

Licensure as a Small Family Day Care Home capacity of 8 children ages under 18 years will be recommended effective June 5, 2020.

SUPERVISOR'S NAME: Duane MatsubaraTELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma LomeliTELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2020
LIC809 (FAS) - (06/04)
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