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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700476
Report Date: 06/22/2023
Date Signed: 06/22/2023 11:28:48 AM

Document Has Been Signed on 06/22/2023 11:28 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SAMOILENKO, SVITLANA & KAMYNINA, YULIIAFACILITY NUMBER:
015700476
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Applicants Svitlana Samoilenko and Yuliia KamyninaTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Jyoti Saini conducted a scheduled pre-licensing inspection this day, arriving at 9:15 am and meeting with Applicants Svitlan Samoilenko and Yuliia Kamynina. LPA and Applicants inspected an entire home for Health and Safety Hazards. Applicants rent this house. The applicant lives in this house with Co-applicant Yulia Kamynina and her son. Both applicants primarily speak Russian. The applicant’s sister Maryna Koroliuk was there to help translate. The home consists of 3 bedrooms including Master bedroom attached Bathroom, hallway bathroom, hallway two closets, living room, dining room, kitchen, backyard, and garage. There are three (3) storage sheds in the backyard and one(1) detached room which will be exclusively used as painting room by the applicants and will be off limit from the children in care. Per applicants, family childcare’s operating hours are from Monday-Friday 7:30am-6:00pm.The applicants also plan to provide care during the weekends.

ON LIMIT AREAS are the dining room, living room (main play area), bedroom #3 (master bedroom and adjacent bathroom) located on the right side of the hallway and backyard.

OFF LIMIT AREAS: Bedroom #1 and bedroom #2 located on the left side of the hallway, hallway bathroom, two closets in the hallway, garage, detached room in the backyard and three storage sheds in the backyard.

The home appears to be neat and clean with heating and ventilation for safety and comfort. The ISOLATION AREA will be the living room. All off limit areas are properly barricaded. Home has a working smoke and carbon monoxide detector, a working telephone, and a fully charged Fire Extinguisher. There are no pools, hot tubs, or any other bodies of water on the premises. All hazardous materials and toxins are kept out of the reach of children. The applicants will be providing lunch and snacks. Applicant states discipline policy is redirection. Per Applicants, they may or may not purchase liability insurance, applicants were advised to use form, the Affidavit regarding liability insurance for FCCH. Parent's Right and the Emergency Disaster Plan were Posted. Applicants were advised to post the License when they received it. Applicants were also advised to conducts fire/disaster drills once every six months, and to log the date and time of the drill. LPA discussed safe sleep guidelines and 15 minutes check requirements.

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SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SAMOILENKO, SVITLANA & KAMYNINA, YULIIA
FACILITY NUMBER: 015700476
VISIT DATE: 06/22/2023
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The applicant’s Health and Safety training is completed, and CPR and First Aid certificate is current and expires 04/25. There are no wall heaters in the home. The fireplace is barricaded with the toy storage. The applicants mandated reporter training is complete. Applicants are reminded of NO walker, exersaucers, jumpers, bouncers, and any similar items to be used for children in care and shall be made inaccessible. Smoking is prohibited in family childcare homes. The Applicants are reminded any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

Review of records to be maintained -LPA reviewed with applicants the LIC 311D, Forms/Records to Keep in Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicants.

APPLICANT KNOWS PROSPECTIVE CLIENTS WILL NEED IMS:


This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan for Providing 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) or (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

Safe Sleep :LPA discussed the safe sleep regulations with applicants 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 [applicant, licensee, or facility representative] 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.
Applicants was reminded that all adults 18 and over living in the home, persons who provide care and
supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.
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SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
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: SAMOILENKO, SVITLANA & KAMYNINA, YULIIA
FACILITY NUMBER: 015700476
VISIT DATE: 06/22/2023
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MyChildCarePlan.org-- Applicants were informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Subscribe to CCLD important information
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.
To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Prior to the licensure:

**Control of property.


-A copy of the lease or rental agreement is needed indicating both the applicant's name.

-Property Owner Landlord Consent LIC9149

Exit interview conducted and report was reviewed with the applicants, Svitlan Samoilenko and Yuliia Kamynina

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

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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