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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400702
Report Date: 07/11/2024
Date Signed: 07/11/2024 10:50:32 AM

Document Has Been Signed on 07/11/2024 10:50 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/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
07/11/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Samaria Dombrovsky, LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Dayna Chambers conducted a case management- licensee initiated inspection on July 11, 2024, for the purpose of a capacity increase. LPA arrived at the facility at 9:30AM and met with Samaria Dombrovsky, Licensee who guided analyst on a tour of the facility. Per Licensee, operation hours are 7:30am to 5:30pm Monday through Friday, closed Saturday, and Sunday. There are 7 children that are currently enrolled. A current children’s roster was available for review. There were 4 children present upon arrival. 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, 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. Licensee is seeking Department authorization to use the backyard area for children. LPA requested a Safety Statement written by licensee that will be reviewed by the Department. Currently, there is a declaration stating the licensee will not use the backyard for children. 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. The licensee provides food for children in care. Individuals who reside in the home were noted and discussed. Per Licensee, they currently have two assistants. All adults present in the home have obtained a criminal record clearance or exemption prior to working, residing, or volunteering in the licensed childcare home. 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 cellphone, and the cellphone stays at the facility during operation hours. There is ventilation and heating via central heat and air conditioning.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE: DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/11/2024
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: DOMBROVSKY FAMILY CHILD CARE
FACILITY NUMBER: 198400702
VISIT DATE: 07/11/2024
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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 01/04/2024, as indicated on service tag. Smoke and carbon monoxide detectors were tested and are operable. Licensee states that she is currently caring for infants. Licensee states that infants sleep in the activity room 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. Infants shall be checked on every 15 minutes and the time of each 15-minute check shall be documented with child’s name and date. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age. LPA observed sleep charts for the two enrolled infants. The licensee is observed to be operating within the license capacity limitations. Licensee does not provide transportation. 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 and staff do have proof of immunizations against: MMR, TDAP, TB Clearance, and declination of influenza.
LPA observed that the Licensee and staff 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. All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. Last drill documented was conducted on 07/01/2024. There are no pets on the premises. 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. Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: DOMBROVSKY FAMILY CHILD CARE
FACILITY NUMBER: 198400702
VISIT DATE: 07/11/2024
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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. Licensee owns the home and has proof of control of property on file. 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, available at: http://www.ada.gov/childqanda.htm Incidental Medical Services. LPA reviewed with licensee 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. Entrance Checklist was provided to the applicant. LPA discussed the safe sleep regulations with [applicant, licensee, or facility representative] 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 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. On this date, 07/11/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ. Licensee was informed of the MyChildCarePlan.org site, 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: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: DOMBROVSKY FAMILY CHILD CARE
FACILITY NUMBER: 198400702
VISIT DATE: 07/11/2024
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A notice of site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

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

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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

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.


At this time, the licensee is in compliance with California Code of Regulations Title 22. No deficiencies cited.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Dayna Chambers
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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