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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409296
Report Date: 04/16/2025
Date Signed: 04/16/2025 12:37:11 PM

Document Has Been Signed on 04/16/2025 12:37 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:GELFMAN, LARISAFACILITY NUMBER:
073409296
ADMINISTRATOR/
DIRECTOR:		GELFMAN, LARISAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 300-8880
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
04/16/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:34 AM
MET WITH:Gelfman, LarisaTIME VISIT/
INSPECTION COMPLETED:
12:51 PM
NARRATIVE
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On 04/16/25 at 8:30am Licensing Program Analysts (LPA) Mario Caro conducted an Unannounced Annual Inspection at Larisa Gelfman's Family Day Care Home. LPA met with Licensee, explained the purpose of today’s inspection, and was granted permission to enter the facility. Days and hours of operation are Monday - Friday from 7:00 am - 6:00 pm. Present in the home were Licensee, 2 fingerprint cleared adults, 6 preschoolers, and 4 infants in care. LPA toured all ON-LIMIT areas of the home.

LPA observed sufficient materials, toys, and play equipment for the day care children in the home. Furniture and equipment, such as cribs, mats, feeding chairs, and tables were age appropriate and in good condition. The home is sanitary, orderly, and safe for the day care children. The home is equipped with central heating and ventilation. The vents are located on the floor but do not get hot to the touch. The Licensee has a working telephone in the home. LPA observed a fully charged 3A-40-BC fire extinguisher. Licensee's last emergency drill was conducted 10-30-2024. The Licensee states that she does not have any weapons in the home. Licensee has a small dog that is kept separate from the day care. The Licensee states that she does not transport children. Licensee didn't have a PUB 394 parents rights poster posted on her wall nor LIC 995 parents rights notification forms signed in her children's files which imposed a potential risk to the health, safety, or personal rights of clients. A Type B deficiency will be cited see deficiency page 809D. Licensee didn't have signed medical consent forms in 5/6 children's files which imposed a potential risk to the health, safety, or personal rights of clients. A Type B deficiency will be cited see deficiency page 809D. Licensee's assistant and husband were missing there preventive health completion certificates a technical violation was issued.
NAME OF LICENSING PROGRAM MANAGER: Mayla Mendoza
NAME OF LICENSING PROGRAM ANALYST: Mario Caro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/16/2025 12:37 PM - It Cannot Be Edited


Created By: Mario Caro On 04/16/2025 at 10:57 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: GELFMAN, LARISA
FACILITY NUMBER: 073409296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(b)
Admission Procedures and Authorized Representatives Rights
(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above because she didn't have a PUB 394 parents rights notification poster posted for parents to review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/16/2025
Plan of Correction
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LPA Caro printed a PUB 394 parents rights certificate for licensee to post and she posted it on her parent board. POC cleared by visit.
Type B
Section Cited
CCR
102417(g)(7)
operation of a family child care home

(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in 5 out of 6 children's files were missing signed medical consent forms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2025
Plan of Correction
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Licensee will submit evidence of a signed medical consent form LIC 627 for each child listed on the roster. Licensee may submit the evidence to LPA Caro via email to Mario.Caro@dss.ca.gov by POC date 04/30/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Mayla Mendoza
NAME OF LICENSING PROGRAM MANAGER:
Mario Caro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GELFMAN, LARISA
FACILITY NUMBER: 073409296
VISIT DATE: 04/16/2025
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Licensee hasn't been documenting 15 minute checks on a sleep log to adhere to the infant safe sleep regulations. Licensee stated they sit next to the infants in the same room as they sleep, and she will document the times on a log moving forward. A technical violation was issued. Licensee's assistant hasn't completed the mandated reporter training. A technical violation was issued. Licensee's assistant hasn't obtained a MMR immunization and/or couldn't provide evidence one was given. A technical violation was issued. Licensee had one enrolled child whom didn't have proof of immunization's in his file. A technical violation was issued. Licensee had blankets in 4/6 infants cribs and one infant laying in another on top of a loose sheet that was tied to the inner corners of the crib. A technical violation was issued.

ON LIMITS: Living/Dining, kitchen, Storage room converted into Large Play Room, Son's bedroom converted into Play/Nap Room, Master Bedroom (for naps), Hall Bathroom, Half Bathroom attached to large play room

OFF LIMITS: The Entire Level 2 which comprises of 1 Bedroom, 1 Bathroom, Office

Children's and Licensee's files were reviewed. Licensee's CPR/First Aid certification and Mandated Reporter training is current and updated.

Supervision of children was discussed with the Licensee and he understands that he must be present in the home during 80% of the operating hours of the day care and ensure that the children are supervised at all times.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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 are available at: https://www.ada.gov/resources/child-care-centers/.
NAME OF LICENSING PROGRAM MANAGER: Mayla Mendoza
NAME OF LICENSING PROGRAM ANALYST: Mario Caro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: GELFMAN, LARISA
FACILITY NUMBER: 073409296
VISIT DATE: 04/16/2025
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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 web page 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.

On 04/16/25 , the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

In the areas that were evaluated, 2 regulatory type B violation were cited.



A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Exit interview conducted, appeal rights were provided, and report was reviewed with the licensee Larisa Gelfman.
NAME OF LICENSING PROGRAM MANAGER: Mayla Mendoza
NAME OF LICENSING PROGRAM ANALYST: Mario Caro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC809 (FAS) - (06/04)
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