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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313786
Report Date: 07/09/2021
Date Signed: 07/09/2021 02:37:57 PM

Document Has Been Signed on 07/09/2021 02:37 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:ZOLOTUKHINA, KRISTINAFACILITY NUMBER:
304313786
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Kristina Zolotukhina, licenseeTIME COMPLETED:
03:00 PM
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An inspection was conducted at the facility by Licensing Program Analyst (LPA) Mila Quinto. The LPA toured the facility with licensee, Kristina Zolotukhina. A review of facility personnel report summary indicates that all facility residents, staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Due to COVID 19 guidelines, LPA observed staff and following CDC and Dept of Public Health Guidelines. There are presently 2 adults including the licensee living in the home. During today's inspection the home and grounds were toured, there were no children in care at the time of the visit. Operating hours are 8am - 6pm, Monday through Friday.

The facility is a two-story home with 4 bedrooms, 3 bathrooms, living room, dining room, kitchen, family room, and backyard that is fenced. The licensee designated the family room, one bathroom, and backyard as part of her day-care. Licensee has placed the second story as off limits and has placed child proof gates and door handles to prevent the children from entering the off-limit areas during operation hours. The licensee acknowledged the children may never enter the off-limit areas. The outdoor area is free from hazards.
Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. The licensee stated poisonous items are not stored on site, and none were observed during today's inspection. The home provides safe toys, equipment, and materials. During today's inspection each child was observed to have safe, healthful and comfortable accommodations, furnishings, and equipment. There is a working carbon monoxide detector, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. The facility has conducted an emergency drill within the past six months and log was verified. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's visit.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2021
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: ZOLOTUKHINA, KRISTINA
FACILITY NUMBER: 304313786
VISIT DATE: 07/09/2021
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The licensee's pediatric CPR/First Aid Certificate expires on 2/13/23. Licensee have proof of immunization against pertussis and measles and against influenza (written decline). Children's records were reviewed and in compliance. The licensee has a current roster of children in care. Children’s records were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance.

Beginning March 31, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years, per A.B. 1207. Licensee has completed the required mandated reporter training dated 01/02/2021.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 http://www.ada.gov/childganda.htm.

The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian.

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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: ZOLOTUKHINA, KRISTINA
FACILITY NUMBER: 304313786
VISIT DATE: 07/09/2021
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Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. Licensee has a lead training Certificate. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee. A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP:https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with licensee the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used if they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.
In the areas that were evaluated, NO deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

An exit interview was conducted with Kristina Zolotukhina. 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.
End of Report.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Mila Quinto
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
LIC809 (FAS) - (06/04)
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