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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700322
Report Date: 01/30/2025
Date Signed: 01/30/2025 12:22:16 PM

Document Has Been Signed on 01/30/2025 12:22 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:ARMEEVA, ANNAFACILITY NUMBER:
015700322
ADMINISTRATOR/
DIRECTOR:		ARMEEVA, ANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 322-9126
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
01/30/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:helper, Tetiana Tymchenko.TIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Jyoti Saini conducted an unannounced Annual Random Inspection and met with helper Tetiana Tymchenko. LPA disclosed the purpose of the inspection and was granted entry into the facility by the helper. Present during the inspection were two helpers supervising 10 preschoolers. Upon arrival, the licensee was not present at home due to a medical emergency. The licensee had left the children in the care of the two helpers, one of them has not obtained fingerprint clearance and is not associated with this facility. Therefore, Type A deficiency and an immediate civil penalty was issued. See LIC809D. Licensee's husband arrived during the inspection. The home is a two-story house with four bedrooms, including a master bedroom and master bathroom, two bathrooms, a family room, a kitchen with a dining area, an upstairs loft, a laundry room, a garage, and a backyard. The hours of operation are Monday through Friday, from 8:00 am to 6:00 pm.

On-limits areas include the family room (main daycare area), downstairs bedroom (nap room), downstairs bathroom, kitchen, dining area, and backyard. Off-limits areas are the entire upstairs area and the garage, laundry room downstairs. All off-limit areas are inaccessible by closed and locked doors and are visually supervised.

LPA inspected the house for health and safety hazards. The home has a working telephone, a functioning smoke and carbon monoxide detector, and a fire extinguisher that meets the minimum requirements. During the inspection, LPA did not observe any bodies of water. A fireplace in the daycare room is barricaded with storage boxes. The helper confirmed there are no firearms in the house, and there are no pets present. The outdoor play area is fenced and free from defects or dangerous conditions. There is a trampoline in the backyard, and LPA advised the helpers that the facility must comply with the manufacturer’s instructions for the trampoline, including any supervision requirements, if any daycare children use it. The stairs are barricaded with safety mesh to prevent access to the upper level of the house. Fire drill log indicates that the fire and earthquake drill was conducted on 1/03/2025 and 01/06/2025 simultaneously. Helpers working in the facility today do not have CPR and First Aid records available for department review. (See TypeB LIC809-D)

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SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE: DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
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 01/30/2025 12:22 PM - It Cannot Be Edited


Created By: Jyoti Saini On 01/30/2025 at 10:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: ARMEEVA, ANNA
FACILITY NUMBER: 015700322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(k)
Criminal Record Clearance
(k) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees, volunteers that require fingerprinting and non-client adults residing in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Due to a medical emergency, the licensee had to go to the doctor and left the children in the care of S2, who did not have fingerprint clearance.This poses an immediate risk to the health, safety, or personal rights of the persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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The licensee shall process her helper's fingerprint clearance prior to being in the presence of children in care. The facility shall immediately exclude the helper lacking fingerprint clearance. Staff member was immediately removed from the facility. A civil penalty of $100 is being assessed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wynn Norona
LICENSING EVALUATOR NAME:Jyoti Saini
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/30/2025 12:22 PM - It Cannot Be Edited


Created By: Jyoti Saini On 01/30/2025 at 10:44 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: ARMEEVA, ANNA
FACILITY NUMBER: 015700322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in. Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. No personnel has first aid, CPR on file, which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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There should always be one individual with current pediatric First Aid and CPR training supervising the children. The facility is required to submit proof of enrollment in a CPR/First Aid class or a current certificate to the department for verification by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Wynn Norona
LICENSING EVALUATOR NAME:Jyoti Saini
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2025


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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ARMEEVA, ANNA
FACILITY NUMBER: 015700322
VISIT DATE: 01/30/2025
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Type A and Type B deficiencies are cited today.



Appeal rights were given .

A notice of site visit was given and must remain posted for 30 days.

As per the directions of the licensee's husband, LPA read the report to the licensee over the phone. The licensee acknowledged, understood, and authorized the helper Tetiana Tymchenko to sign the report.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ARMEEVA, ANNA
FACILITY NUMBER: 015700322
VISIT DATE: 01/30/2025
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The licensee provides daily snacks and meals. LPA reviewed the children's files, which were complete and up-to-date. All required postings are properly posted.

During Inspection, Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.


Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years. Training can be taken online at www.mandatedreporterca.com

California Code of Regulations, {Title 22, Division 12, Chapter 1, Section 102370(d) is being cited on the attached LIC809-D. THE LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAY'S VISIT WITH THE NOTICE, AND THE LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR THE AB 633 FACT SHEET AND A COPY OF THE ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.

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SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC809 (FAS) - (06/04)
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