198400702-5-4-2026-54-CC-ACAN-DTRQSN-20260504122550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198400702
Report Date: 05/04/2026
Date Signed: 05/04/2026 12:26:32 PM

Document Has Been Signed on 05/04/2026 12:26 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 CARE		FACILITY NUMBER:	198400702
ADMINISTRATOR/ DIRECTOR:	DOMBROVSKY, SAMARIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(310) 291-0854
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 6	CENSUS: 4	DATE:	05/04/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Samaria Dombrovsky, Licensee		TIME VISIT/ INSPECTION COMPLETED:	12:35 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) Ashley Calderon conducted an unannounced annual/ random inspection to the above facility. LPA identified self and met with Licensee Samaria Dombrovsky who allowed LPA entrance into the facility. LPA discussed the purpose of today's visit. LPA Calderon was guided on a tour of the facility alongside with Licensee S.Dombrovsky. Per Licensee, currently have no assistants. LPA observed 4 children upon arrival; per Licensee has 6 enrolled; two there own children who attend a different school during the day. Two children enrolled are infants, 1 infant present. Licensee was the only adult present during visit, their fingerprint is cleared. Review of LIC9040 children’s roster was available and observed current. Per Licensee, operation hours are Monday through Friday 7:30am to 5:30pm. nThis home is a single story residential home that 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/ pool which is locked and has a safety alarm. On limits: section of the backyard, Living Room #2 , restroom is located in the hallway near living room #1 and the fenced back yard. Off Limits: 4 bedrooms, 2 restrooms, kitchen, dining room, laundry room, attached garage, front yard, and pool.

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

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: 05/04/2026

NARRATIVE

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All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness.

The restroom that children use was observed to be safe and sanitary. LPA did not observe any infant walkers, baby bouncers, inclined chairs, baby saucers, or any similar items at the facility. Age appropriate toys, equipment and materials were observed. Per Licensee states that there are no firearms stored in the home; none observed. LPA observed 1 cat in the home. Per Licensee no poisons are stored in the home; LPA reminded Licensee if brought into the home make sure they are locked. In the main living room #1, LPA observed a fireplace, there is a glass barricade, observed not to be securely bolted, therefore consultation was given. LPA observed cleaning supplies in the cabinets under the kitchen sink and under the off limit bathroom by the dining room; cabinets had latches for inaccessibility. In the kitchen, on the right side, there is a laundry room and that leads to the attached garage which is inaccessible to the children. Knives are stored on top of the kitchen counter, current children are unable to access this area and LPA reminded Licensee to evaluate safety and if inaccessible at all times as circumstance can change per age of children enrolled. The off limit rooms have knobs that lock and observed closed during visit. The home has central heating and A/C unit. The fire extinguisher was observed in the living room #2, with service tag dated 12/9/2025. Carbon monoxide and smoke alarm are interconnected, tested and found operable.

The backyard pool was observed locked and mesh fence observed in good condition, there is an alarm system in place, LPA reviewed daily log, there is a body hook and a life ring available. LPA reviewed Disaster Drill log last drill conducted 5/1/2026. LPA reviewed required postages located in living room #2, observed was Facility License, PUB Notification of Parent Rights and during today's visit LPA provided LIC9148 Earthquake Preparedness form to post. LPA reviewed 4 children files all files had required documentation's in place. Facility carries Liability Insurance with Markel, expires 11/7/2026. Licensee's file was reviewed Pediatric 1st aid and cpr with American Red Cross expires 3/1/2028 and Mandated Reporter expires: 10/28/2026.

Infants present had 15 min sleep log, facility had 2 play yards and 1 crib. Crib had a firm mattress and fitted sheets were available; LPA reminded Licensee if play yards are used for napping must purchase a firm mattress and fitted sheets when use for sleeping infants. Per Licensee, children are now mainly using cots.

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

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: 05/04/2026

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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. 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.

Per California Code of Regulations Title 22 facility had No deficiencies cited. 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.

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

LIC809 (FAS) - (06/04)

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