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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400702
Report Date: 04/14/2025
Date Signed: 04/14/2025 09:18:27 PM

Document Has Been Signed on 04/14/2025 09:18 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:DOMBROVSKY FAMILY CHILD CAREFACILITY NUMBER:
198400702
ADMINISTRATOR/
DIRECTOR:		DOMBROVSKY, SAMARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 291-0854
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
04/14/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Samaria Dombrovsky, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Dayna Chambers conducted an unannounced annual inspection to the above facility on 04/14/2025. LPA arrived at the facility at 9:30AM, identified self, and met with 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. Per Licensee, they currently have one assistant. LPA observed 7 children upon arrival. There are 9 children that are currently enrolled. A current LIC9040 children’s roster was available for review. Per Licensee, operation hours are Monday through Friday 7:30am to 5:30pm. Individuals who reside in the home were noted and discussed. This Home has an in-ground pool in the backyard which meets licensing and AB2866 statutes. 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 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 children use Activity Room #2 for activies, meals, and napping. The children’s restroom is located in the hallway near living room #1.The restroom that children use was observed to be safe and sanitary. The backyard is off-limits. The outdoor play area was observed to be fenced. LPA did not observe any infant walkers, baby bouncers, inclined chairs, baby saucers, or any similar items at the facility. Safe toys play equipment and materials were observed. All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. Off Limit Areas include 4 bedrooms, 3 restrooms, Living Room#1, Dining Room, kitchen, laundry room, attached garage, front yard, and fenced back yard. Licensee states that there are no firearms stored in the home. Licensee states there are no pets on the premises. LPA did observe the in-ground pool. LPA did not observe any spas, hot
NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Dayna Chambers
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: DOMBROVSKY FAMILY CHILD CARE
FACILITY NUMBER: 198400702
VISIT DATE: 04/14/2025
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tubs, fishponds, or similar bodies of water during the inspection. There is telephone service via cellphone and the cellphone stays at the facility during operation hours. There is ventilation and heating via central heat and air conditioning. 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 valve on the required 2A 10BC fire extinguisher indicates fully charged and was serviced on 01/07/2025, as indicated on service tag. The Dual 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 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. 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 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 assistant do have proof of immunizations against MMR (Mumps, Measles, Rubeola), TDAP, TB Clearance, and current influenza or declination. 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. 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 04/04/2025. Per recent AB2866 Water Safety Statutes, the Pool Log was completed with the last inspection date of 04/14/2025. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted. 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
NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Dayna Chambers
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: DOMBROVSKY FAMILY CHILD CARE
FACILITY NUMBER: 198400702
VISIT DATE: 04/14/2025
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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. PIN 22-05-CCP
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.

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.
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 Dombrovsky.


At this time, the licensee is in compliance with California Code of Regulations Title 22. No deficiencies cited.
NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Dayna Chambers
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2025
LIC809 (FAS) - (06/04)
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