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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313419
Report Date: 04/17/2023
Date Signed: 04/17/2023 03:43:08 PM

Document Has Been Signed on 04/17/2023 03:43 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:PRISYAZHNYUK, YULIAFACILITY NUMBER:
304313419
ADMINISTRATOR:PRISYAZHNYUK, YULIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 870-2160
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
04/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Yulia Prisyazhnyuk, LicenseeTIME COMPLETED:
04:00 PM
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LIcensing Program Analyst (LPA) P Rivas conducted an unannounced annual inspection. LPA was met by licensee Yulia Prisyazhnyuk and together toured inside of the home. LPA toured outside home without licensee as there were 5 children napping inside and two children playing outside. LPA also viewed assistant caring for the two infants outside play area. Licensee states the hours of operation are: 8:30am to 5:00pm M - F.
A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. The following was observed and reviewed during this inspection. This is a one-story home which consists of 3 bedrooms and 3 bathrooms. The rooms utilized for the day care are the living room, kitchen and dining room have been changed for day care area. The children use the backyard of the home for outdoor play time. There are no bodies of water on the premises. The backyard was observed to be fenced with age appropriate toys and free of hazards. The Licensee was reminded that full supervision is required at all times to ensure children do not have access to the off-limit areas. The off-limit areas are kept closed during day care hours as stated by licensee. Upstairs area is off limits and has a gate to prevent entry.
There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory
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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PRISYAZHNYUK, YULIA
FACILITY NUMBER: 304313419
VISIT DATE: 04/17/2023
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requirements.
Due to time constrains LPA was only able to do the physical plant tour.

The following deficiency is cited under the California Code of Regulations Title 22 Division 12 on lic 809d -

An exit interview was conducted with licensee Prisyazhnyuk, Yulia. Appeal Rights were explained. The licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2023 03:43 PM - It Cannot Be Edited


Created By: Pat Rivas On 04/17/2023 at 03:28 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: PRISYAZHNYUK, YULIA
FACILITY NUMBER: 304313419

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with Ms. Prisyazhnyuk, the licensee did not comply with the section cited above , and stated she has not conducted a fire drill in over 6 months and does not have the last one documented, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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 Licensee states she will conduct a fire drill and send verification to LPA by plan of correction da
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:Rina Lopez
LICENSING EVALUATOR NAME:Pat Rivas
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023


LIC809 (FAS) - (06/04)
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