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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313419
Report Date: 12/13/2022
Date Signed: 12/13/2022 11:21:48 AM

Document Has Been Signed on 12/13/2022 11:21 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, 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: 7CENSUS: 4DATE:
12/13/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Yulia Prisyazhnyuk, LicenseeTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) P Rivas conducted an unannounced case management visit as a result of LPA's observations during a complaint visit.. Upon entrance LPA met staff Flor Pfeifer and Staff #2(S2). LPA took census and noted 3 children in area with Ms. Pfiefer and one child (c1)in area with S2, Area for for staff #2 is in the daycare room next to the kitchen. Ms. Pfeifer advised that licensee had left on an errand approximately 10 minutes before.(approx 9:00am) The areas were separated by a curtain that blocks view from each area. Licensee arrived at 9:24am.

A review of the Facility Personnel Report Summary on 12/13/2022 indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions

When LPA took census LPA viewed Child #1(C1) and staff #2(S2), Child was sitting in a bench area.

After census was taken LPA stayed in area that Ms. Pfeifer was monitoring and interviewed Ms. Pfeifer. from 9:14 to 9:22am. During Interview LPA was unable to see the next area as it is separated by a curtain.
LPA opened curtain at 9:22 am and noted C1 was sitting alone in the room on the bench with breakfast in front of him. LPA immediately called out twice for s2, LPA could not see staff. After calling out s2 returned to kitchen/day care area and LPA asked where she was. S2 stated she was just here. LPA again asked where she was and then she had gone to the bathroom to get a paper towel to clean C1. LPA then immediately asked why did she leave the room since there were paper towels in the kitchen. Staff stated she forgot because she usually cleans child's hands in bathroom. LPA had view of bathroom and LPA did not see S2 step out of bathroom . LPA could not see staff from where LPA stood next to C1 . LPA observed staff coming from further in the hallway beyond the bathroom.

Cont page 2
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PRISYAZHNYUK, YULIA
FACILITY NUMBER: 304313419
VISIT DATE: 12/13/2022
NARRATIVE
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the time of absence of supervision is unknown. According to LPA's observation the duration of absence might have happened anywhere from a minute to couple of minutes.

Section 102417(a) Operation of Family Home Type A was cited on LIC 809D.
An immediate civil penalty of 500.00 is hereby assessed for absence of supervision for today and 100.00 per day until corrected.

LPA, Patricia Rivas informed licensee, PRISYAZHNYUK, YULIA that this report dated 12/13/2022 document 102417 (a)( Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA, Patricia Rivas informed the licensee to provide a copy of this licensing report dated 12/13/2022 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the licensee PRISYAZHNYUK, YULIA. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 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.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Pat Rivas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2022 11:21 AM - It Cannot Be Edited


Created By: Pat Rivas On 12/13/2022 at 10:27 AM
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: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2022
Section Cited
CCR
102417(a)

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102417(a) Operation of Family Home (a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When... Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. This requirement was not met as evidenced by:
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Staff returned and stayed with C1.Licensee stated that she will train staff and will implement if staff have to leave their respective areas for any reason they will open the curtain so that there can be direct line of site. copy of signed training and new procedure to be sent to LPA by Plan of
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LPA's Observation of C1 sitting alone on bench eating breakfast and no staff was present in area where C1 was sitting. This poses an immediate threat to children in care.
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correction visit.

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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: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022


LIC809 (FAS) - (06/04)
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