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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400702
Report Date: 04/03/2024
Date Signed: 04/04/2024 07:23:48 AM

Document Has Been Signed on 04/04/2024 07:23 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:DOMBROVSKY FAMILY CHILD CAREFACILITY NUMBER:
198400702
ADMINISTRATOR:
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 9DATE:
04/03/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
TIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Samaria Dombrovsky, LicenseeTIME COMPLETED:
TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dayna Chambers conducted an unannounced annual inspection to the above facility on April 3, 2024. LPA arrived at the facility at 9:15AM and identified self and purpose of visit. LPA was greeted by Samaria Dombrovsky. Licensee who guided analyst on a tour of the facility. LPA provided Licensee with a copy of the LIC 126 Entrance Checklist to help facilitate the inspection. LPA observed that also present during this inspection, was Jocelyn Ixcoy, Licensee’s Assistant. LPA observed 8 children upon arrival. LPA confirmed infants ages and observed there were 5 infants in care, and 3 additional children. LPA observed at approximately 11:37am, another child arrived making the count of children 9 which is over ratio and capacity for a small family home. LPA observed upon arrival that the licensee is not operating within the license capacity limitations. Per Licensee, operation hours are 7:30AM to 5:30pm Monday through Friday and Closed Saturday and Sunday. There are 9 children that are currently enrolled. A current children’s roster was not available for review, the roster was incomplete.
This Home has a pool in the backyard which meets licensing regulations.
This is a one -story home that consists of 4 bedrooms, 3 restrooms, Living Room#1, Living Room #2, Dining Room, kitchen, laundry room, attached garage and Front yard and fenced back yard. The children use Activity Room #2 for activies, meals, and napping. The children’s restroom is located in the hallway near living room #1. 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 is currently off-limits to children in care. The backyard is fenced.
The backyard has a pool that is fenced. During prelicensing, 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. The licensee uses Bixby Knolls Park for children’s activities. The children will not use the front yard for play.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 04/04/2024 07:23 AM - It Cannot Be Edited


Created By: Dayna Chambers On 04/03/2024 at 01:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: DOMBROVSKY FAMILY CHILD CARE
FACILITY NUMBER: 198400702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102391(b)
Inspection Authority of the Department
(b) The licensee shall permit the Department to inspect the family child care home, and to privately interview children or staff, to determine compliance with or to prevent violations of family child care laws or regulations. The Department shall exercise this authority as specified in Health and Safety Code Section 1596.8535(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on last inspection on 03/26/24, LPA was unable to gain entry into home for inspection. Staff 1 and Staff 2 denied entry at 9:15am to 10:30am. Per licensee, they were at a conference in Los Angeles, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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LPA provided the regulations for inspection authority and operation of a family home for training. Licensee will train the staff on all regulations. LPA will provide training videos from the CCLD website
Type A
Section Cited
CCR
102416.5(b)(2)
Staffing Ratio and Capacity
(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (2) Six children, no more than three of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. Upon arrival at 9:15am, LPA observed 5 infants and 3 additional children in the home At 11:37am, an additional child arrived at the home for care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2024
Plan of Correction
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Licensee will have to notify parents, revise the children's care schedules with parents, disenroll children if needed to meet the appropriate ratios/capacity. Licensee will need to train staff on regulations. LPA will provide training videos from CCLD website.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Valarie Cook
LICENSING EVALUATOR NAME:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


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Document Has Been Signed on 04/04/2024 07:23 AM - It Cannot Be Edited


Created By: Dayna Chambers On 04/03/2024 at 01:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: DOMBROVSKY FAMILY CHILD CARE
FACILITY NUMBER: 198400702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above , licensee did not complete the roster with 6 of the 9 children enrolled, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/08/2024
Plan of Correction
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Licensee will complete the roster and email a copy of the roster in PDF form to LPA's email by 04/08/24. Licensee will continue to update the roster when needed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Valarie Cook
LICENSING EVALUATOR NAME:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


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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: 04/03/2024
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Per Licensee, all areas are off limits to children and parents except for the children’s restroom and Activity Room #2. The licensee provides food for children in care. Individuals who reside in the home were noted and discussed. Per Licensee, they currently have one assistant but will be qualifying two more assistants.
LPA observed one dog in the backyard and is inaccessible to the children in care during operation hours.
Licensee states that there are no firearms stored in the home. All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. There is telephone service via cellphone and the cellphone. Licensee was reminded that the cell phone remains at the home during operation hours. There is ventilation and heating via central heat and air conditioning. Safe toys play equipment and materials were observed. Detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock. The restroom that children use was observed to be safe and sanitary. The valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 01/24/2024, as indicated on service tag. The home has dual Smoke and carbon monoxide detectors, and they were tested and are operable. Licensee states that she currently cares for infants. Licensee states that infants sleep in activity room #2 where they are constantly supervised. Appropriate sleeping arrangements and cribs were observed. (One crib for each infant in care was observed. Cribs or play yard did not hinder the entrance or exit from the sleeping space, mattresses shall be firm and covered with a fitted sheet that overlaps the underside so it cannot be dislodged. Cribs and play yards were observed to be free of loose articles and objects. No objects were observed to be hanging above or attached to the side of the crib. LPA did not observe any infants swaddled while in care. Licensee is following the safe sleep regulations with sleep charts and LIC9227 infant sleep plan in the files. Per licensee, they do not provide transportation. LPA observed two car seats in living room #1. LPA advised licensee to place the car seats in a room that is not accessible. LPA did not observe any children sleeping in car seats. The licensee and other personnel have completed training on preventive health practices including Pediatric First Aid and CPR. The licensee's Pediatric First Aid and CPR expires on 03/16/2026 There are first aid supplies available. LPA advised that if a child shows signs of illness, he/she/they shall be separated from other children. Children’s records were reviewed, including emergency information, and were observed to be complete. The licensee does have proof of immunizations (MMR, TDAP, TB Clearance, and influenza declination). LPA advised placing copies in the staff file for review during inspections. LPA observed that the Licensee and assistant do have proof of the Mandated Reporter AB 1207 compliant Child Care Training Certificate on file. LPA issued a Confidential Names List (LIC 811) to the licensee which documents staff and children’s files reviewed during this inspection.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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Document Has Been Signed on 04/04/2024 07:23 AM - It Cannot Be Edited


Created By: Dayna Chambers On 04/03/2024 at 01:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: DOMBROVSKY FAMILY CHILD CARE
FACILITY NUMBER: 198400702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. Licensee did not have a documented drill log available during inspection. LPA could not confirm any emergency drills were conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Licensee will conduct a drill and log it and email the drill log to the LPA in PDF form by 04/05/24. Licensee will be provided with CCLD videos to watch and train staff.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Valarie Cook
LICENSING EVALUATOR NAME:Dayna Chambers
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024


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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: 04/03/2024
NARRATIVE
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All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Licensee did not have a drill log available during inspection. LPA was unable to verify the last drill conducted. LPA did observe the pool in the backyard. This pool was approved by the Department upon prelicensing and meets the licensing regulations. LPA did not observe spas, hot tubs, fishponds, or similar bodies of water during the inspection. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories are not permitted in a family childcare facility. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home. 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 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 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. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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/.
Licensee was informed 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.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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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: 04/03/2024
NARRATIVE
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During the exit interview, the LICENSEE ****, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

The following deficiencies listed on the attached deficiency page are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

Title 22, Division 12, Chapter 1, Article 04. Enforcement Provisions
Inspection Authority of the Department
102391(b) Inspection Authority of the Department
(b) The licensee shall permit the Department to inspect the family childcare home, and to privately interview children or staff, to determine compliance with or to prevent violations of family childcare laws or regulations. The Department shall exercise this authority * as specified in Health and Safety Code Section 1596.8535(a).

Title 22, Division 12, Chapter 1, Article 06. Continuing Requirements
102416.5 (b)(2)
Staffing Ratio and Capacity

(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following:

(1) Four infants; or

(2) Six children, no more than three of whom may be infants: or
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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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: 04/03/2024
NARRATIVE
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Title 22, Division 12, Chapter 1, Article 06. Continuing Requirements
Operation of a Family Child Care Home

(8) Each family childcare home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
H&S
Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.

Title 22, Division 12, Chapter 1, Article 06. Continuing Requirements
102417(g)(9)(A)1


(A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

1. The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home.

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee/Director was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the licensee/Director.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Samaria Padilla.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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