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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195700153
Report Date: 09/21/2023
Date Signed: 09/21/2023 12:21:44 PM

Document Has Been Signed on 09/21/2023 12:21 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:PASECHNIKOVA FAMILY CHILDCAREFACILITY NUMBER:
195700153
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
09/21/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:SVETLANA PASECHNIKOVATIME COMPLETED:
01:00 PM
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On 09/20/2023 Licensing Program Analyst (LPA) Lisa Clayton conducted an ANNOUNCED PRE-LICENSING INSPECTION with applicant Svetlana Pasechnikova. Hours of operation are Monday – Friday, 8:00am – 6:00pm. Applicants will provide breakfast, lunch, snacks and dinner.

The home was toured with the applicant for a health and safety inspection.

The current facility sketch was reviewed, and LPA confirmed that the home consists of the following: living room, dining/family room, kitchen, laundry room, 3 bedrooms, 2 full bathrooms, and fenced backyard.

The Applicant has requested the following rooms be ON-LIMITS: the living room (day care area), dining/family room (day care eating/activity area) bedroom #2(napping/classroom), bedroom #2 (classroom), bathroom #1, and the fenced back yard. The ISOLATION AREA will be in the living room daycare room.

The applicant has requested the OFF-LIMIT AREAS are as follows: kitchen, laundry room, and bedroom #1, and bathroom #2, all of which are inaccessible to children in care by child safety gates, closed and/or locked doors and visual supervision. The property has an ADU unit (address 23302 Bassett St, West Hill, CA 91307) applicant is aware and acknowledges that she is not to provide care to children at the ADU.

The home is neat and clean with heating and ventilation for safety and comfort. The FCCH has a working phone and LPA Clayton confirmed the number is 818-516-9627.

The home has a fully charged 2A:10: BC Fire Extinguisher, a working carbon monoxide detector/smoke detector combo, and two working smoke detectors.


SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PASECHNIKOVA FAMILY CHILDCARE
FACILITY NUMBER: 195700153
VISIT DATE: 09/21/2023
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There are no pools, jacuzzi, hot tubs, ponds, or bodies of water on the premises. Any poisons, detergents/cleaning compounds, medication and hazardous items that can pose a danger to children are inaccessible to children in care. Per applicant, there are no firearms in the home.

LPA Clayton observed age-appropriate toys, books and furnishing and equipment that are in good condition, free of sharp, loose or pointed parts. Playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. Areas around high climbing equipment have cushioning material to absorb falls.

The Applicant and her fingerprint cleared assistant have current CPR/First Aid certificates and Mandated Reporter Training certificates. LPA Clayton observed documents showing the applicant and her assistant are in compliance with the immunization law which pertains to day care providers.

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and­resources/safesleep as an additional resource. LPA also informed Monica of the importance of checking for recalled infant devices on the United States Consumer Products 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 the purchased equipment.



California Law requires Family Child Care Home applicants 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 electronic mail. Roster of the children must be properly maintained, and fire/disaster drill every six months must be documented. Please report Telephone number changes and/or if you move from home.

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/.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PASECHNIKOVA FAMILY CHILDCARE
FACILITY NUMBER: 195700153
VISIT DATE: 09/21/2023
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LPA provided applicant with the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. LPA Rios gave applicant a packet of allre quired forms. posters and covid related material. The following forms are required in a Family Child Care home:

CHILDREN'S RECORDS REQUIREMENTS

· LIC 700 Identification and Emergency Information

· LIC 627 Consent for Emergency Medical Treatment


· LIC 282 Affidavit Regarding Liability Insurance
· LIC 9150 Parent Notification Additional Children in Care
· LIC 9927 Individual Infant Sleeping Plan
· LIC 995A Notification of Parent’s Rights
· LIC 613A Personal Rights
· Immunization Record
FACILITY RECORDS:
· LIC 624B Unusual Incident/Injury Report
· LIC 9040 Child Care Facility Roster
· LIC 9052 Employee Rights,
· LIC 9108 Statement Acknowledging Requirement to Report Child Abuse
· LIC 9149 Property Owner/Landlord Consent Form
· LIC 9151 Property Owner/Landlord Notification Form
· Proof of current pediatric CPR and First Aid Certificates
· Copy of your deed or lease/rental agreement
· Documentation of Fire and Disaster drills
· Proof of immunizations against pertussis (TDAP), measles (MMR), and influenza
· Mandated Reporter certificate – www.mandatedreporterca.com – must be renewed every two (2) years.

FORMS TO BE POSTED

· LIC203 Facility License

· LIC 610A Emergency Disaster Plan


· LIC 9148 Earthquake Preparedness Checklist
· PUB394 Notification of Parents Rights Poster
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PASECHNIKOVA FAMILY CHILDCARE
FACILITY NUMBER: 195700153
VISIT DATE: 09/21/2023
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In addition, LPA Clayton informed applicant of the following:
o There is an effective 24/7 ban on smoking tobacco in a home that is licensed as a family day care home, and in those areas of the family day care home where children are present.
o Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
o Saucer chairs, bouncers, walkers, or any similar items are prohibited.
o All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
o LPA provided and advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

The applicant is reminded any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. Applicant was reminded of Departments inspection authority, with or without any notice.

Applicant Svetlana was advised of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.



Applicant was reminded that all adults 18 and over living or working in the home, 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.

During the exit interview, applicant Svetlana confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: PASECHNIKOVA FAMILY CHILDCARE
FACILITY NUMBER: 195700153
VISIT DATE: 09/21/2023
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

This home is recommended for licensing on 09/21/2023. This report shall remain on file for 3 years. Exit interview conducted applicant.

An exit interview was conducted, and report was reviewed and provided to applicant. A notice of site visit was provided and must remain posted for 30 days.
SUPERVISORS NAME: Karren Starks
LICENSING EVALUATOR NAME: Lisa Clayton
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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