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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409394
Report Date: 12/11/2024
Date Signed: 12/11/2024 12:53:56 PM

Document Has Been Signed on 12/11/2024 12:53 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:RYBICKI, LAURENFACILITY NUMBER:
073409394
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
12/11/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:LAUREN RYBICKITIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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On 12/11/2024 at 9:00am Licensing Program Analyst (LPA) Tasha Alexander met with Licensee Lauren Rybicki for an ANNUAL/RANDOM and INCREASE OF CAPACITY inspection . Present during the inspection was the Licensee, her assistant Jessica Hathorn, and 6 preschool age children in care. Licensee lives in the home with her husband, Faraz Khanzadeh, and two minor sons, ages 5 years old and 2.5 years old. Licensee’s home was toured for a health and safety inspection. The facility operates from 8:00am – 5:00pm, Monday - Thursday. 8:00am to 4:00pm Friday.

ON LIMITS AREA: living room, 2 bedrooms, dining room, kitchen, and the right side of the backyard where the shed is located.
OFF LIMITS AREA: Entire upstairs which consists of 3 bedrooms and 1 bathroom.
ISOLATION AREA: family room

The facility is a two-story home owned by the Licensee and her husband. The inside 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. Licensee stated that children bring lunch from home. Licensee provides am and pm snacks. All food that is brought from the children’s home is properly labeled and stored. Licensee states that she does not transport children. There is one pet dog in the home. There are no firearms in the home per licensee.
There is one (1) fully charged 2A10BC fire extinguisher in the kitchen. There is one (1) working smoke detector and carbon monoxide detector located in the hallway near the day care room. The fireplace in the family room is screened making it inaccessible to the children in care. Licensees uses highchairs and age appropriate tables and chairs for eating. There are four play yards used for sleeping. All napping equipment is clean, well maintained and in proper working order. The home is equipped with central heat and air for proper ventilation.
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: RYBICKI, LAUREN
FACILITY NUMBER: 073409394
VISIT DATE: 12/11/2024
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The backyard is fully fenced, clean and has ample age appropriate materials for the children in care. There is a play structure that has been anchored into the ground for extra safety. There are storage areas in the back yard that is inaccessible to the children. LPA did not observe any harmful bodies of water in or around the home.

Licensee is operating within their licensed capacity and is in ratio. Licensee’s Health and Safety training with Lead Poisoning component has been completed and Pediatric CPR and First Aid training is complete and expires 2/2025. Licensee’s Mandated Reporter training is complete and expires 9/23/24, assistant 9/5/24. LPA obtained the fire/disaster drill log, log is complete with the last drill logged 8/28/24. 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 obtained the children’s files, helper's file and facility roster. All files were complete.

Licensee was 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.
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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: RYBICKI, LAUREN
FACILITY NUMBER: 073409394
VISIT DATE: 12/11/2024
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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 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 Licensee Lauren Rybicki.
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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