<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073403875
Report Date: 04/04/2024
Date Signed: 04/04/2024 04:26:36 PM

Document Has Been Signed on 04/04/2024 04:26 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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:WCISLO, LUCYNA & JANUSZFACILITY NUMBER:
073403875
ADMINISTRATOR/
DIRECTOR:		WCISLO, LUCYNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 470-0977
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
04/04/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:LUCYNA WCISLOTIME VISIT/
INSPECTION COMPLETED:
04:30 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 4/4/2024 at 1:30pm Licensing Program Analyst (LPA) Tasha Alexander met with Licensee's assistants Halina Swiderka and Anna Sienko for an ANNUAL/RANDOM INSPECTION. Per assistant Halina, licensee is away today on vacation. Present during the inspection were both assistants, three (3) infants and five (5) preschool age children in care. Licensee lives in the home with her husband/co licensee Janusz Wcislo and 1 adult son Sabastian. Licensees' home was toured for a health and safety inspection. The facility operates from 7:00am – 6:00pm, Monday - Friday.

ON LIMITS AREA: Playrooms (2), hallway bathroom, living room, and side portion of the backyard
OFF LIMITS AREA: All bedroom, kitchen
ISOLATION AREA: Living Room

The facility is a single-story home owned by the Licensee and her husband. The day care areas of the home was observed to be neat, clean with ample age-appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Halina stated that the licensees provide all food for the children. Assistant also stated that Licensees do not transport children. There are 2 pet dogs in the home. Per assistant, there are no firearms in the home.

There is one (1) fully charged 2A10BC fire extinguisher in the childcare room. There is one (1) working smoke detector in the childcare room. There is one carbon monoxide detector in the hall way near the bathroom. The fireplace in the living room is locked making it inaccessible to the children in care. Licensees use highchairs and age appropriate tables and chairs for eating. There are 2 play yards used for sleeping. All napping equipment is clean, well maintained and in proper working order. The home is equipped with central heat. Licensees have installed an air conditioning unit in the childcare room for proper ventilation.

Continued on 809-C
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: WCISLO, LUCYNA & JANUSZ
FACILITY NUMBER: 073403875
VISIT DATE: 04/04/2024
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
26
27
28
29
30
31
32
The backyard is fully fenced, clean and has ample age appropriate materials for the children in care. There is a swimming pool located in the backyard secured with a self-latching gate that swings away from the pool and meets the California State Fire Marshal standard.

The facility is operating within the licensed capacity and is in ratio. Assistant Anna has current CPR & 1st AID training card which expires in 2025. Assistants are unable to locate the Mandated Reporter training certificates today. LPA obtained the fire/disaster drill log, log is not up to date with the last drill logged 9/9/2022. All adults living and working in the home have obtained a criminal record clearance. All required forms are posted in the childcare room by the entrance door. LPA was unable to obtain the children’s files, nor the helper's files. The facility roster is up to date.

Assistants were reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.
Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com

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. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (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.

Continue on 809-C
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: WCISLO, LUCYNA & JANUSZ
FACILITY NUMBER: 073403875
VISIT DATE: 04/04/2024
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
26
27
28
29
30
31
32
Assistants were 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.

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/process.

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.

Exit interview conducted and report was reviewed with Assistant Halina Swiderska.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 04/04/2024 04:26 PM - It Cannot Be Edited


Created By: Tasha Hackett-Alexander On 04/04/2024 at 03:58 PM
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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: WCISLO, LUCYNA & JANUSZ
FACILITY NUMBER: 073403875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY A REVIEW OF RECORDS WHICH REVEALED THE FIRE/DISASTER DRILL LOG IS NOT UP TO DATE. LAST DRILL CONDUCTED 9/2022
POC Due Date: 04/18/2024
Plan of Correction
1
2
3
4
LICENSEES WILL CONDUCT A FIRE/DISASTER DRILL WITH CHILDREN IN CARE, DOCUMENT AND SUBMIT A COPY OF THE UPDATED LOG TO COMMUNITY CARE LICENSING BY 4/18/24

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:Mayla Mendoza
LICENSING EVALUATOR NAME:Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 04/04/2024 04:26 PM - It Cannot Be Edited


Created By: Tasha Hackett-Alexander On 04/04/2024 at 03:58 PM
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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: WCISLO, LUCYNA & JANUSZ
FACILITY NUMBER: 073403875

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(10)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY LPA OBSERVATION WHICH REVEALED A BABY ROCKER/BOUNCER IN THE HOME
POC Due Date: 04/05/2024
Plan of Correction
1
2
3
4
LICENSEE WILL REMOVE THE ROCKER/BOUNCER FROM THE HOME BY THE NEXT BUSINESS DAY.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9