198400702-3-14-2023-54-CC-DCHS-CPWQEA-20230314120601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198400702
Report Date: 03/14/2023
Date Signed: 03/14/2023 12:06:11 PM

Document Has Been Signed on 03/14/2023 12:06 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME:	DOMBROVSKY FAMILY CHILD CARE		FACILITY NUMBER:	198400702
ADMINISTRATOR:	DOMBROVSKY, SAMARIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(310) 291-0854
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 8	CENSUS:	DATE:	03/14/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Samaria Dombrovsky, Applicant		TIME COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dayna Chambers conducted a pre-licensing inspection on March 14, 2023. Entrance Checklist was provided to the applicant. LPA met with Samaria Dombrovsky, Applicant, who guided analyst on a tour of the facility. During the inspection individuals residing in the home were discussed and noted. The applicant is requesting a Small Family Home license. Per applicant, operation hours will be Monday through Friday 7:30am to 6:00pm, closed Saturday and Sunday. Applicant states they will care for children 3 months to 6 years of age. All areas identified on the facility sketch were inspected, including but not limited to, off- limit areas. This is a one -story home that consists of 4 bedrooms, 3 restrooms, Living Room#1, Dining Room, and Kitchen. On Left side by entry way: Bedroom #1 – (office). Through the living room #1 there are two entry ways on left and right side. Through the right side: family room #2 will be used as activity room. Passed activity room #2 is Bedroom #2 (master bedroom/bathroom). From living room #1, the hallway on left side leads to Bedroom #3 on the right, bathroom #2 in middle of hallway, and end of hallway, bedroom #4. Note: The activity room #2 will be used for children. The glass sliding patio door has a lock mechanism that uses a key to open the sliding patio door. Also, installed on the sliding patio door is a door alarm with voice sound alarm for safety. All doors in the rooms of the home have a voice alarm installed The kitchen also has a door that leads to the patio which is locked and has a safety alarm. In the kitchen, on the right side, there is a laundry room and that leads to the attached garage. The backyard will be off-limits to children in care. The backyard is fenced. The backyard has a pool that is fenced. The fencing surrounds the pool. The fencing measures a length of five feet high. The mesh fencing is strong enough to withstand the impact of toys and does not bend upon impact. `LPA measured the length and width of fence surrounding the pool. The fence does no obstruct the view of the pool. The bottom of the pool fence measures a 1” inch gap from the ground to the start of the fencing. The gate swings away from the pool and is a self-close, self-latching lock. There is a pool slide installed. LPA took photos of the pool area. LPA obtained a signed declaration from applicant stating the backyard and pool is off-limits to children in care. The backyard will not be used for children at any time. The applicant’s neighborhood has a park that children will use with authorization by parents. (P1 continued)

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: DOMBROVSKY FAMILY CHILD CARE	FACILITY NUMBER: 198400702
	VISIT DATE: 03/14/2023

NARRATIVE

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The children will not use the front yard for play. Per applicant, the children will use the restroom located through activity room #1 in middle of hallway. Children will use family room#1 for activities and use family room #2 for activities, napping, and meals. Areas used by children were inspected for safety, comfort, and cleanliness. Telephone service is a cell phone and will remain in the home during daycare hours.
Ventilation and heating are installed via central heat and air. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children were not observed in the restroom, kitchen or family room or in the off-limit areas of the home. LPA did not observe observed poisons in the laundry room or other areas of the home during the inspection. LPA advised applicant that all poisons must be locked with a key or combination lock. LPA observed the cleaning items were placed in a top shelf in kitchen.
Based on the Facility Sketch submitted, areas off limits to children and parents are: 4 Bedrooms, 2 bathrooms, kitchen, laundry room, backyard and garage. The off-limits rooms have locks. The applicant will need to install a barrier to make the kitchen off-limits to children as stated by applicant. The home has a RING security system installed and cameras installed outside. The applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary. The children will not use the back yard for outdoor play at any time. LPA obtained a declaration. The backyard was observed to be fenced. The applicant states they will use the neighborhood park and that children will always be physically and visually supervised.
Per applicant, there are no firearms or weapons on the premises. LPA observed one dog and this dog will not be accessible to children in care during operation hours. LPA observed a pool in the backyard. The backyard will not be used for children in care at any time. LPA obtained declaration. The valve on the 3A10BC fire extinguisher indicates fully charged, the service tag states that the 3A10BC size extinguisher was serviced on 01/13/2023. Smoke and carbon monoxide detectors were tested to ensure that they are operable. The applicant has one working dual carbon monoxide and smoke detector in activity room #1. LPA recommends installing additional smoke/carbon detectors near activity room #2. There are toys available for children. LPA observed two napping cots for children. Applicant will need to purchase infant equipment. The applicant states that they will provide food for children in care. If food is not provided and food is brought from the children’s homes; container shall be labeled with child’s name and properly stored or refrigerated. The applicant has completed the required Health and Safety Training, Nutrition & Lead Training. Applicant’s Pediatric First Aid and CPR expires on 03/12/2024. There are first aid supplies available.
In the absence of the licensee, a qualified adult must be present supervising the children. A qualified adult is an individual who has: CURRENT MANDATED REPORTER – EXPIRES EVERY TWO YEARS:
(P2- Continued)

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: DOMBROVSKY FAMILY CHILD CARE	FACILITY NUMBER: 198400702
	VISIT DATE: 03/14/2023

NARRATIVE

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WWW.MANDATEDREPORTERCA.COM
PEDIATRIC FIRST AID AND CPR CERTIFICATE – EMSA APPROVED ONLY – RENEW EVERY TWO YEARS. LIC 9108 – STATEMENT ACKNOWLEDGING REQUIREMENT TO REPORT CHILD ABUSE. IMMUNIZATIONS: MMR, TDAP, CURRENT INFLUENZA OR DECLINATION STATEMENT, AND TB CLEARANCES, FINGERPRINT CLEARANCES – CACI, DOJ, FBI – ASSOCIATED TO FACILITY.
Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated. The fire extinguisher type -2A-10BC -must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
LPA provided applicant with a “capacity chart” for enrolling children. Per LIC279B, advised applicant that two children are included in capacity as of 03/14/23. Reporting Requirements: Unusual Incidents/Changes should be reported to the Department within 24 hours /as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home. Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Fire and safety drills must be performed every six months and documented for review by the Department. Example Fire Drill Log was provided to applicant. Smoking is prohibited in a family childcare home. Children and Staff records must be maintained and updated as needed and must be available for review by the Department. LIC 311D was provided to applicant. No smoking, no infant walkers, No Johnny jumpers, no saucer chairs, no trampolines and any other item that falls into that category are not permitted in the facility. Smoking on the premises is prohibited. 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. Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients. Liability Insurance was discussed. LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.·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 or declination, MMR, TDAP, and TB Clearance (current). The licensee and all adults working with children have proof of immunization. Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com Mandated reporter expires every two years. Licensee is responsible for renewing. Per applicant, there are no dual licenses at this address. Applicant inquired about resource family/foster care. Applicant’s email address was obtained during this inspection. The applicant was advised that email may be public information. (P3-Continued)

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: DOMBROVSKY FAMILY CHILD CARE	FACILITY NUMBER: 198400702
	VISIT DATE: 03/14/2023

NARRATIVE

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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. LPA signed applicant up for quarterly updates.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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

LPA discussed the safe sleep regulations with applicant about infant safe sleep regulations and procedures. LPA 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 provided applicant with Title 22 regulations for safe sleep, PIN 20-24CCP, Example Infant Sleep Chart, Infant Safe Sleep FAQs, copy of LIC9227, and Never shake a baby flyer.
LPA also informed applicant 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.
A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted and report was reviewed with the applicant, Samaria Dombrovsky.
Corrections Before Department Will Approve License:
1. Pool Area (will need approval by Department – additional procedures and steps might need to be implemented before approval.
2. Proof of Infant Equipment for at least 1 infant
3. Kitchen needs a barrier to make “off-limits” to children per applicant
4. Create/Install a Parent Board – LIC311D provided to assist applicant
5. Install an additional smoke/carbon detector for activity room #2 (P4-end)

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC809 (FAS) - (06/04)

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