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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197494997
Report Date: 04/28/2023
Date Signed: 05/04/2023 10:40:39 AM

Document Has Been Signed on 05/04/2023 10:40 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:BUBENNOVA FAMILY CHILD CAREFACILITY NUMBER:
197494997
ADMINISTRATOR:ANZHELA BUBENNOVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 385-7058
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
04/28/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Anzhela BubennovaTIME COMPLETED:
02:50 PM
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Forum: Zoom
Date: 04/28/2023 at 1:00 p.m.
Victor Bautista, Regional Manager
Emiko Bell, Licensing Program Manager (LPM)
Judy Laureano, Licensing Program Analyst (LPA)
Svetlana Pasechnikova- Applicant
Anzhela Bubennova- Licensed facility 197494997

The purpose of this office meeting is to discuss a pending application for a small family childcare home license.

Areas of concern:
This is an ADU on the property of currently licensed Large Family Child Care

During visits by Licensing Program Analysts (LPA)s to the home they will be looking to verify that applicant still resides at 23302 Bassett Street. Applicant understands that any change which occurs with the operations of the family child care home or facility needs to reported to the Department as a soon as possible. Licensee understands that any incident occurs, each facility is responsible for submitting an unusual incident report if it effects their program, making a clear distinction whose facility is being impacted.

Licensee confirms that currently her mother, and two other adults work in the day care; Irynia Sudorzhenko, Alexandra Komarova and Olena Prokopenko. Licensee has been advised to ensure that all individuals are associated to the license by May 1st, 2023.

Licensee confirms that parents have been notified that my program will be sharing the outdoor space with applicant’s and an outdoor schedule will be followed with applicant. Outdoor space will be used 8:00 a.m. to 900 a..m and 5:00 p.m. to 6:00 p.m. Applicant confirmed that parents will use the side
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2023
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: BUBENNOVA FAMILY CHILD CARE
FACILITY NUMBER: 197494997
VISIT DATE: 04/28/2023
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entrance and will not have any contact with 23302, property 23302 will use the front entrance for families.

During visits by Licensing Program Analysts (LPAs) to the home they will be looking to see that both Licensees are present in their respective home.


Copy of this report will be provided to Licensee, Anzhela Bubennova.
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Judy Laureano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023
LIC809 (FAS) - (06/04)
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