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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700537
Report Date: 08/14/2024
Date Signed: 08/14/2024 01:28:44 PM


Document Has Been Signed on 08/14/2024 01:28 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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:BURLIBEKOVA FAMILY CHILD CAREFACILITY NUMBER:
197700537
ADMINISTRATOR:SHOLPAN BURLIBEKOVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 287-6173
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY:14CENSUS: 6DATE:
08/14/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Shoplan Burlibekova, LicenseeTIME COMPLETED:
01:45 PM
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On Wednesday, August 14, 2024, at 10:30 a.m., Licensing Program Analyst (LPA) Mayra Rivera conducted an unannounced annual inspection and met with licensee Shoplan Burklibekova who granted access and guided LPA Rivera on a tour of the facility.

Family members residing in the home have been discussed with licensee and are cleared. LPA observed 6 preschool children present. LPA observed facility to be within ratio. Operating hours are Monday to Friday from 8:30 a.m. to 5:00 p.m. and care for children ages 0-13 years old. Annual fee is current. LPA did not observe co-licensee Aida and LPA explained the 80/20 rule.

This facility is a one-story home that consists of 3 bedrooms, 2 bathrooms, kitchen, living room, dining room, family room, attached garage and front and backyard fenced.

Areas off limits to children include- living room, kitchen, dining area, master bathroom #1, bedroom #3 and garage. LPA observe safety gates barriers to prevent children access to the kitchen and living room and safety locks on doorknobs.

Areas accessible to children include- bathroom located in the hallway, bedroom #2, family room and backyard.

At approximately 10:45 a.m., LPA Rivera inspected the facility for safety, comfort, cleanliness, ventilation and working phone (cell phone). For ventilation, LPA Rivera observed central AC/heater and the vents located on the ceiling. LPA observed the furniture, children’s materials, to be in good condition and age appropriate. LPA observed a fireplace in the living room and observed the metal screen cover strapped. LPA did not observe infant furniture or materials due to no infant in care during this visit.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BURLIBEKOVA FAMILY CHILD CARE
FACILITY NUMBER: 197700537
VISIT DATE: 08/14/2024
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LPA Rivera observed cleaning compounds items, stored underneath the kitchen sink, and observed a childproof lock in place, making it inaccessible for children to open. LPA observed the knives and sharp objects stored inside the kitchen drawer with a childproof lock making it inaccessible for children to open. For water drinking, licensee stated she provides water bottles. The licensee stated the facility provides meals and snacks. LPA informed licensee any food brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated. Licensee stated she currently does not have any children with severe food allergies nor on medication.

At approximately 10:54 a.m., LPA Rivera entered the bathroom and observed the toilet, hand washing sink, hand soap and LPA observed the bottom sink cabinet closed and did not observe hazard materials and observed the bathroom to be in good condition. LPA reminded licensee any personal items (ex; shampoo, toothpaste, mouthwash, or items that fall into that category) must be made inaccessible to children.

LPA Rivera asked the licensee if there were any pets, poisons, firearms, weapons, or bodies of water. The licensee stated she has no pets, no poisons and no bodies of water, no firearms, and no weapons. LPA did not observe pets, poisons, firearms, weapons, nor bodies of water. The licensee was informed that if any poisons (ex; drano, rat poison or items that fall into that category), firearms and weapons are purchased, it is required to be locked with a key or combination lock and firearm and ammunition/firing pins must be stored separately.



At approximately 10:59 a.m. LPA Rivera observed the required 2A10BC fire extinguisher located in the kitchen and the valve on the green area indicating fully charged and purchased receipt dated 1/4/2024. LPA observed a dual carbon monoxide detector and smoke alarm located in the hallway. Licensee tested the dual carbon monoxide and smoke alarm. LPA Rivera heard the sounds and are operable. LPA observed the first aid complete with band aids, gauzes, adhesive bandages, and antiseptic wipes and located in the hallway closet. For ill isolation, licensee stated she utilizes a corner of the daycare room. LPA observed the last emergency drill conducted on 7/9/2024.

At approximately 11:06 a.m., LPA Rivera inspected the play outdoor (backyard) area that is utilized by children for safety, comfort, and cleanliness. LPA observed the backyard to be fenced and side gates closed and with a self-latch lock. LPA observed the play equipment to be age appropriate and in a safe condition, free of sharp, no lose or pointed parts. The surface of the outdoor activity space is maintained in a safe
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
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
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BURLIBEKOVA FAMILY CHILD CARE
FACILITY NUMBER: 197700537
VISIT DATE: 08/14/2024
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condition and is free of hazards. LPA Rivera did not observe high play structure equipment. For outdoor water drinking, children bring out their water bottles.

LPA Rivera observed licensee Pediatric First Aid/ CPR certification dated 6/20/23 and Health and Safety certification dated 10/10/21, and licensee has proof of immunization against Pertussis, MMR, and Influenza declination. Licensee has completed the Child Abuse Mandated Reporter (AB 1207) training dated 10/1/23.

LPA observed the postings License, LIC 9148 Earthquake Preparedness Checklist, LIC 610A Emergency Disaster Plan, Pub 394 Notification of Parents Rights, and LIC 999 Facility sketch. LPA also reviewed children’s roster and children files. LPA did not observe sleep logs because currently has no children under 2 enrolled.


The following was also discussed with the licensee:

1. The following items are zero tolerance by Licensing: Refused Entry to a Facility or Any Part of a Facility is a violation of Section 1596.852, 1596.853 or 1597.09. Regulations 101238 (g) (2), The Presence of an Excluded Individual, Fire Clearance Violations, Accessible Bodies of Water, Accessible Firearms, Ammunition or Both

2 Pediatric First Aid and CPR: American Heart Association or American Red Cross or Emergency Medical Services Authority (EMSA) approved in Pediatric First Aid and CPR must be present. Certification must be renewed every two years.

3. Licensee was informed that the mandated reporter training must be completed every 2 years, and is available at www.mandatedreporterca.com

4. In the absence of the licensee a qualified adult must be present, supervising the children; a qualified adult is an individual who has a valid and current Pediatric first aid/ CPR-adult-child- infant certification (EMSA approved), a valid criminal record clearance associated to the facility license, immunization's (MMR, TDAP, TB and Influenza or Influenza declination), AB 1207 Child Abuse Mandated Reporter Certificate.

5. A current roster of children enrolled must be available and maintained for a period of 3 years, even after children are no longer attending the facility.
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BURLIBEKOVA FAMILY CHILD CARE
FACILITY NUMBER: 197700537
VISIT DATE: 08/14/2024
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6. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the license shall be terminated.
7. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary and smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

8. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

9. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing (refer to LIC 624B).

10. Fire and safety drills must be performed every six (6) months and documented for review by the Department.

11. Smoking is prohibited in the family childcare home.



12. Children and staff records must be maintained and updated as needed and be available for review by the Department.

13. Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The licensee and all adults working with children have proof of immunizations.

14. Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.



15. The facility license number must be on all advertisements, publications, or announcements with the intent to attract clients.

16. Isolation for Ill children: When a child is ill, he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).
SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BURLIBEKOVA FAMILY CHILD CARE
FACILITY NUMBER: 197700537
VISIT DATE: 08/14/2024
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17. Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

18. Dog(s) and/or pets are recommended to be isolated from children in care.

19. No, no infant walkers, no Johnny jumpers, no saucer chairs, and any other item that falls into this category is not permitted in the facility.



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.

Licensee Shoplan Burklibekova 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.

LPA discussed the safe sleep regulations with licensee Shoplan Burklibekova and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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: https://www.ada.gov/resources/child-care-centers/.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
PALMDALE CC RO, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: BURLIBEKOVA FAMILY CHILD CARE
FACILITY NUMBER: 197700537
VISIT DATE: 08/14/2024
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Licensee Shoplan Burklibekova was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Licensee Shoplan Burklibekova confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Two technical violations given for:

102417(a)- (a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. (The co-licensee must follow the 80/20 regulation).

102417(m)(3)- (3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state. (Children files missing LIC 282 Affidavits)

During this visit, no deficiencies. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted, and report was reviewed with the assistant Rustam Khairullin.

SUPERVISOR'S NAME: Lady KingTELEPHONE: (661) 202-3318
LICENSING EVALUATOR NAME: Mayra RiveraTELEPHONE: (661) 603-1090
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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