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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313623664
Report Date: 11/15/2021
Date Signed: 11/15/2021 12:10:22 PM

Document Has Been Signed on 11/15/2021 12:10 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:EYVAZOVA, GULSHANFACILITY NUMBER:
313623664
ADMINISTRATOR:EYVAZOVA, GULSHANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 537-3208
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
11/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gulshan Eyvazova - LicenseeTIME COMPLETED:
12:30 PM
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An unannounced annual/random inspection is made today by LPA Katrina Owens. Present at time of inspection were licensee, her assistant and 12 day care children. Ages of children present were 2,2,1,2,3,2,3,10 months, 4,2,3,and 2 years old. Licensee is not a Foster Parent, nor have any other licenses.

A tour of the home, inside and outside, as shown on the facility sketch is conducted. Staff and Children were spoken to during inspection. Licensee states there are no weapons or firearms in the home. Swimming pool is fenced per Title 22 regulations. LPA observed poisons, cleaning compound's, medications and other hazardous items are inaccessible to children. There is no fireplace. Fire extinguisher, Carbon Monoxide Detector and Smoke Detector meets regulations. Currently, licensee does have one dog. She chooses to allow the dog to have access to day care children and she is aware that she is responsible for child safety around pets at all times. Stairs are barricaded when children under age 5 years old are present. Toys and play equipment that were observed appear to be safe. There is a working telephone. Adequate supervision is being provided during this inspection. Children are supervised when outside in any unfenced play area. LPA did not observe sleeping plan for each infant under 12 months old present. LPA reviewed 15 minute check log document.

LPA discussed the safe sleep regulations with licensee [or facility representative] and discussed the Child Care Licensing Safe Sleep web page 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.

Continued on next page.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Katrina Owens
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: EYVAZOVA, GULSHAN
FACILITY NUMBER: 313623664
VISIT DATE: 11/15/2021
NARRATIVE
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The capacity as specified on the license is being maintained. Staff-child ratios are maintained. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Licensee, Gulshan Eyvazova, 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.

Pediatric CPR/FA is current with expiration date of 7/22/2022. A child roster is maintained. Fire and disaster drills are conducted every six months and documented. Children records reviewed.

LPA observed proof that licensee and staff/ volunteers have met the requirements of SB 792.

LPA observed that all staff has completed the required mandated reporter training (AB 1207) at website: www.mandatedreporterca.com

LPA discussed the Effects of Lead Exposure brochure.


This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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/childqanda.htm No children are currently on medication at this time.

Continued on next page.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Katrina Owens
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
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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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: EYVAZOVA, GULSHAN
FACILITY NUMBER: 313623664
VISIT DATE: 11/15/2021
NARRATIVE
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Off-limit rooms are: Entire upstairs, downstairs bedroom, Garage and Trampoline area behind a fence. Licensee acknowledges that children may never enter these off-limit areas. Swing set observed and is anchored into ground. Observed tow tool shed in backyard and it locked by key lock.

During the exit interview, LPA discussed AB 633, Parent Notification Requirements, and the posting of licensing inspection notices and reports. Hours of operation are 7:30 AM to 5:30 PM; Monday thru Friday and other hours as arranged.
Licensee states she does transport children.

LPA provided the Community Care Licensing website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised licensee of their responsibility to stay current in regards to new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws childcareadvocatesprogram@dss.ca.gov.

Exit interview conducted and report was reviewed with the licensee, Gulshan Eyvazova.

Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, the following deficiencies are found: (see next page 809-D)

The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these
rights.

THIS REPORT SHALL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.

A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Katrina Owens
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2021 12:10 PM - It Cannot Be Edited


Created By: Katrina Owens On 11/15/2021 at 11:22 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: EYVAZOVA, GULSHAN
FACILITY NUMBER: 313623664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(d)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation. Licensee has a baby exersaucer at the facility for infant's use.
This is a potential risk to children.
POC Due Date: 11/16/2021
Plan of Correction
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Licensee states she will remove or put in an off limit area of the facility.

Licensee was informed if deficiency is not corrected by due date a civil penalty may be assessed.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review, the licensee did not have a completed roster at the facility. This is a potential risk to children. LPA gave licensee a Roster form a time of inspection.
POC Due Date: 11/19/2021
Plan of Correction
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Licensee will complete a roster and send a copy of the current roster to LPA by POC date.

Licensee was informed if deficiency is not corrected by due date a civil penalty may be assessed.
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:Keven Peters
LICENSING EVALUATOR NAME:Katrina Owens
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/15/2021 12:10 PM - It Cannot Be Edited


Created By: Katrina Owens On 11/15/2021 at 11:22 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: EYVAZOVA, GULSHAN
FACILITY NUMBER: 313623664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not have a completed Infant Sleeping Plan (LIC 9227)
for the infant under 12 months in care. This is a potential risk to children.
POC Due Date: 11/19/2021
Plan of Correction
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Licensee stated she will have the form LIC 9227 completed by the necessary parties and put in child's file at the facility. She will send a copy of the completed LIC 9227 to LPA by POC date. LPA gave licensee LIC 9227 at time of inspection.
Licensee was informed if deficiency is not corrected by due date a civil penalty may be assessed.
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:Keven Peters
LICENSING EVALUATOR NAME:Katrina Owens
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021


LIC809 (FAS) - (06/04)
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