503911280-4-28-2021-04-CC-NLOI-C2HS4P-20210428133303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 503911280
Report Date: 04/28/2021
Date Signed: 04/28/2021 01:33:13 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 CARE		FACILITY NUMBER:	503911280
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 4	DATE:	04/28/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Kimberly Glukhovskiy		TIME COMPLETED:	01:45 PM

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 April 28, 2021, Licensing Program Analyst (LPA), Norma Lomeli conducted an inspection where facility will be operating under the Emergency Waiver. Present at time of inspection was licensee, Licensee’s Assistant, Diana Mateyashchik and four day care children. Licensee, her husband and her two minor children reside in the home. Verified licensee’s CPR and First Aid was completed through Pediatric Plus with Emergency Medical Services Authority stickers (EMSA) and expires on April 30, 2022. Licensee’s Assistant, Diana Mateyashchik completed the training through American Red Cross and expires on February 19, 2023. Background criminal record clearances are verified and discussed, and LIS 531 is signed indicating that the adults living in the home and/or providing care and supervision to children have a criminal record clearance. Fire clearance was granted on April 13, 2021. A tour of the home, inside and outside, as shown on the facility sketch, was conducted and the following was discussed and/or observed: Fire clearance was received on April 14, 2021. Fire alarm is located on the home’s entry way on the right hand side wall. LPA observed children size furniture, safe toys, books and instructional materials for the children. Children were napping on mats and an infant was napping in a play yard. Firearms are stored in accordance with Title 22 Regulations and ammunition is stored locked separate in accordance with Title 22 Regulations. Poisons are kept inside a locked shed that is located in the backyard. Facility has 2A10BC fire extinguisher, carbon monoxide alarm, working smoke alarm and first aid kit in place. (Continued on LIC809-C):

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma Lomeli	TELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

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: 04/28/2021

NARRATIVE

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Licensee 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.
Licensee is advised that smoking is prohibited on the premises of a family chi care home as specified in Health and Safety Code Section 1596.795(a). Licensee states the home is smoke-free.
Licensee states she does transport day care children. Licensee understands that she must have proper restraints and/or car seats for all the children under her care when transporting children.
Required items are posted in the Child Care Home where parents may easily view.
During visit capacity worksheet was provided and discussed.
Licensee completed the Mandated Reporter Training on June 6, 2020. Licensee’s Assistant completed the training on March 29, 2021.
LPA discussed safe sleep pending regulations and Safe Sleep Regulation Concepts were given licensee.

LPA & licensee discussed the Community Care Licensing website: LPA and licensee discussed new additions to the website that include the new PIN (Provider Information Notification) and information for providers including the Quarterly Update that informs licensees of new legislation and regulations. Please follow these steps go to http://www.cdss.ca.gov/, click on “information and resources” click “Community Care Licensing” Click “quarterly updates” click “Child Care advocates program” and register to PIN.

Licensee states her hours of operation are Monday through Friday from 6:45 AM to 4:30 PM and as arranged. Licensee advised she does not provide overnight care, less than 24 hours. Licensee is advised she may access forms and updated information on the CCLD website at www.ccld.ca.gov.

The home meets the description of a safe and healthy environment for children and is adequate to operate under the Emergency Waiver. Licensure to operate under the Emergency Waiver will be recommended effective April 29, 2021.

During exit interview, LPA observed licensee post the Notice of Site Visit on parent’s board and understands it must remain posted for 30 days and retain evaluation report for 3 years.

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Norma Lomeli	TELEPHONE: (559)650-7870
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021

LIC809 (FAS) - (06/04)

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